THE BIRTH OF SCARLETT

I remember clearly the first time that Katy experienced the reality of childbirth. She was 15 years old at the time. I had been working as a midwife for several years at Acuario, which at that time was the only and pioneer natural childbirth clinic in Spain. Acuario gave childbirth back to women at a time when medicalized/hospital birth was not only the ‘norm’ but highly recommended as the only safe way to deliver a baby. I had already birthed my first three children in my own home when I met with the Acuario team so was not in need of any convincing that child birth belonged to women, belonged to parents, childbirth was a normal physiological process and in most cases was much better carried out with the attendance of a well qualified midwife in a conducive environment, a homely environment, whether that be the mothers actual home or somewhere like Acuario. I spent many years working ‘on-call’. My services would be required at any time day or night to attend births at Acuario or in women’s’ own homes. I was almost always ‘on-call!’ Christina (not her real name) was just 15 years old; she was the teenage daughter of a work colleague. She had hidden her pregnancy for as long as she could but when finally it became impossible to hide any longer she told her mum and came to see us at Acuario. I first met her in the scanning room. I remember touching her abdomen and commenting that I felt she was at least four weeks more than diagnosed by the Ultra Sound Scan. I still rely strongly on my abdominal palpation skills over USS when the first scan is carried out in an advanced gestational age. In those few minutes I connected to Christina in a special way, she was the same age as my own daughter; she could have been my daughter. During the short time that remained of her pregnancy we met many times and I promised I would be with her when she delivered her baby. The call came early one Saturday morning. I was at home with my children. I don’t even remember why she came with me ..…but Katy came with me. On arriving at Acuario and entering the delivery room I found Christina laboring in the warm water of our birthing pool. She was accompanied by her mother and a colleague of mine was also present. Katy came too. She sat discreetly on the rocking chair in the corner of the room and witnessed the whole experience. Christina was laboring well. Her contractions were coming fast and strong and I could see that she was close to pushing her baby out. The whole atmosphere in the room was of love and caring. Supported by her mother, other friendly familiar faces and a well experienced midwife (myself) she confidently rode the waves of pain and turbulence to receive her new baby into the world amidst the smiles and tears of those around her. Katy was there. I don’t actually remember talking with Katy after the experience, although I’m sure we did, but I do remember years later overhearing a conversation she was having with a friend about childbirth and in relating the birth of Christina’s baby was heard to say: “….afraid of childbirth? Oh no!....If she can do it like that at 15 years old…I certainly can!” In our household my children were well used to hearing all the details of the births I had attended, especially the home births and the many very special and beautiful experiences that women were having as they received their sons and daughters into the world with my professional help, guidance, care and love. I don’t think I ever discussed childbirth at home in any other way than as a wonderful, incredibly powerful experience that was totally within the innate instinctive capacity of the female mind and body. A ‘good birth experience’ was totally achievable by the majority of women. It was women’s numerous fears and anxieties that are directly interfering in the birthing process. Healthy,confident, secure, instinctive women who believe in themselves and their bodies, in the whole process of reproduction were more likely to have a successful, positive, uncomplicated experience. I spoke as a midwife who had accompanied so many women and parents through childbirth but also as a mother who had birthed her own four children in the comfort and ‘normality’ of her own home. I spoke always with confidence and security so I suppose this was what my children received during their childhood and formative years. So the way was firmly set for my eldest daughter, as she approached her own decision as to where and how she would birth her own child. Katy had always referred to me being present in the birth of her children, but I certainly never took it for granted, so when the day came and she announced the news of her first pregnancy I waited patiently and silently for her decision. I think she just took it for granted that I knew I would be there, not only as her Mum but as her midwife. I was anxious to ensure that the decision was also supported by my son-in-law Nick. I needn’t have worried as he expressed very clearly that he would only feel secure in having the baby at home if I was present. I guess that if it wasn’t enough to have accompanied so many women in labour and received so many babies into the world during my 15 years working with Acuario not only in the birthing center but also numerous home births I now had 4 years experience in Malawi delivering babies under extremely challenging circumstances with very little back up in the way of medical staff or equipment. These years of being part of the wonder of natural birth and the power and strength of women without option of pain relief or epidurals with only the most basic materials and equipment and lack of true vigilance and accompaniment during labour and birth has all led to reinforce my convictions and beliefs that we women have amazing bodies and souls that are designed beautifully for caring for our children both in and out of the uterus. That babies are strong and determined, hardy souls fighting for survival even before they are born The female body works…. babies are born safe and well and mothers are washing their own soiled cloths just one hour after birth and walking long distances to their homes 24 hours later. It never ceases to amaze me. Of course it doesn’t always work; childbirth has always carried its risks. Vigilance, awareness and the appropriate skills and actions in the case of sudden emergency situations, are vital for safe outcomes, for saving the lives of mothers and babies in any environment but especially in my work in Malawi. During Katy’s pregnancy I was often asked by amazed colleagues and friends how I could feel comfortable attending my own daughter during childbirth? My answer was clear. How could I possibly NOT attend her? I have accumulated so much knowledge and experience over the years that I knew had helped so many women, as well as all that I had felt and learned during the births of my own four children, how could I not share this with my own daughter, to help her? I am her Mum…I am a midwife. I wasn’t able to be physically present with Katy during her pregnancy as I was still in Malawi but I followed it closely with frequent photos and phone calls. I would like to have been around more but I needed to keep all my holidays to ensure I would be present for the birth. It was sometimes difficult to be so far away especially when she was feeling low or sick or just needed some advice. With telephone calls and e mails I would talk to her of the pregnancy, of the birth, answer her questions and reassure her of her ability and capability as a woman and as a mother. I was happy to hear of her visits to the midwives who supported her decision to home birth. I was happy to hear of her NCT meetings where both she and Nick were able to freely discuss their feelings and decisions and continue to feel supported. I was happy to hear that Nick was supporting her, caring for and loving her as together they approached the moment when they would receive their little one into their family. The baby was due around 16th December. I confidently booked my flight to arrive in London on 10th. Somehow I knew this would be fine. Once she knew I was in the UK Katy was anxious for me to be close so on 14th December I saw my first born, MY baby, with her beautiful swollen belly, carrying her own baby. What an amazing moment that was! The following days past quickly and comfortably as we filled them with preparation not only for the baby but for Christmas. My younger daughter was with us much of the time excitedly, lovingly, supporting her big sister. As her due date came and went Katy began to experience those impatient feelings known to each and every heavily pregnant mother. We made bets on when the baby would arrive whilst Katy waited for those first signs of labour. She was waiting to feel pain, that’s such a good thing! I vaguely remember hearing movement during the night as Katy began to feel the first discomfort of labour and started to move around her bedroom. By 5.30am I was awake and knew that labour had started but I stayed in my bed reading my book and awaiting her call. At 7am. she and Nick went downstairs. I could hear Katy retching and vomiting so decided it was a good time to see if I was needed. “We were just going to call you!” Katy exclaimed. She had been having mild contractions since around 2am. They had been gradually increasing in strength so she decided to get up from her bed and find more comfortable positions. All was well…. Nick was with her holding the bucket, holding her hand and giving her the love and comfort that she needed. She had the Tens machine attached to her lumbar area which seemed to be helping but now she needed to have an idea of the progress of labour. After a quick hug and words of encouragement I put on my midwife hat and performing her first vaginal examination found that she was 2cms dilated. All was well… the baby’s head was well down in the pelvis and the cervix was thin and soft, just ripe for a smooth transition into the active phase of labour. I had brought my small ‘doppler’ along so we were all able to listen to the strong healthy heart beat of the little one inside as she too rode the turbulence of the uterine contractions that were slowly but surely facilitating her descent and passage into the outside world. Most of this time Katy was sitting or lying over her birthing ball, rolling her pelvis to aid the descent of her baby which gave her relief from the increasing discomfort as labour progressed. Nick was always close by whilst I preoccupied myself with my own things, remaining close, but lovingly distant. Katy was coping extremely well. Her positive attitude, full understanding of the process of labour, her self-assurance and confidence in the strength and ability of her body to birth her baby were highly evident. As a mother I loved and cared for her with words of praise and encouragement, as a mother who knows her daughter Katy is a strong, capable and decided woman and that her body is naturally able to birth her child safely. As a midwife it was evident to me that the labour was progressing well, the baby was in good condition and the mother was in her chosen environment with the support of the persons of her choice. All was well…. Katy understood that she was still in the early phase of labour and needed to save her energies for the later stages. She took comfort from the use of the TENS machine or the back massages, the small distractions and nutritive snacks provided by Nick and the security of her own home, her chosen midwife, her beloved husband and her mum.(That’s just two people!) Around 11am Katy needed to find a new way to cope as the contractions increased. It seemed a good time for her to take a hot shower or bath to relax her mind and her body and help her to focus. She now needed to isolate herself from outside distractions allowing her body to take over without resistance, allowing her body to increase the production of endorphins and take her into its own world of acceptation and instinctive response. She was now 4cms dilated. The baby’s heartbeat remained healthy and strong. All was well… Once the bath was filled to the top with warm water and lavender drops to aid relaxation Katy entered the water. She gained immediate relief as the heat penetrated her tense muscles and allowed her body to relax and her mind to give up all resistance and accompany the contractions as they pushed her baby’s head down onto the cervix, stretching and dilating with ease. As all resistance left her it became obvious that her body increased its production of Oxytocin and the contractions became more frequent, longer and more powerful progressively. All was well… As her midwife I explained clearly at each stage what was happening in her body, I reassured her that all was well and that what she was feeling was good, it was ‘OK.’ As her Mum I truly knew her strength and conveyed my love and pride in how well she was managing each and every stage. I was close, but not too close, Nick was there…Katy had all she needed. During my time at Acuario I had learned the best use of water in labour and birth. At this stage it would not be beneficial for Katy to remain too long in the bath. There are many other ways of easing the discomfort and the warm water could be kept as an option for a later stage. So after one hour I encouraged her to leave the water and rest awhile in the familiarity, comfort and security of her own bed. It was now 12.15pm. Lying on her side with Nick snuggled up behind her, a hot water bottle on her lower abdomen I sat on the floor by her bedside with my hand on her belly and talked her calmly and quietly through each and every contraction for the next one and a half hours. As the contractions became longer and stronger I could see that Katy would need to find a new way to relieve the pain. She expressed the urge to pee and began to feel pressure low down in the birth canal. It was now 1.45pm. All was well… Now Katy was finding it hard to ride the storm of the contractions. The strength and intensity was at its maximum. All the signs showed that she was close to delivering her baby…but…could that really be true? It had been far too quick for a first time mum! I must admit to thinking that if she was just 5or 6cms, which would have been the average expectation for a first labour, then how would I help her through the next several hours? I suggested she go to the bathroom to pee whilst I prepared a nice warm bath for her. This she did. It was the first contraction that came fierce and strong as she sat on the loo that gave her that unmistakable urge to bear down. Now I knew for sure…the baby was close, she was ready to push. We once more listened to a healthy heat beat from inside her uterus. All was well… We helped Katy into the bath and as she settled into the comforting warm water the next powerful contraction came and she spontaneously and instinctively pushed down deep into the birthing canal and we had our first sight of the little ones’ head covered in dark hair. At this point I suddenly remembered we should inform the local midwife who was prepared to attend the birth. I quickly called the local birthing centre, “I am calling for Katy who is booked with you for a home birth. I’m sorry to leave it so late but things have progressed very fast and she is now in second stage and we can see the baby’s head! All is well…” I’m not sure she believed me as she knew I was a midwife so probably thought I had planned it that way (which I hadn’t) but she spoke very kindly and said she would be along straight away .At this point both Katy and Nick experienced a small moment of panic, of realization that this was the moment they had been waiting for and suddenly it was a bit too much, a bit scary. I spoke to them calmly but firmly to allay their fears and keep them focused. I immediately realized that this was now Rachel the midwife talking, Rachel the midwife with all her skills and knowledge who had taken over my whole being. Rachel the midwife who automatically and instinctively knew how to take this precious woman and her baby safely through childbirth as she had done so many times for so many women and babies. Like most other first timers Katy held back her true power with the first few pushes. Why on earth would a woman cause herself so much pain as she is stretched wide open? Much better to hold back, to resist, trying to lessen the pain. But this is short lasting and with the right encouragement and support Katy quickly realized that she must use all her power, all her strength and determination to safely birth her baby. It took Katy just 30 minutes to push her little one out into this world. The local midwife arrived just two pushes before Scarlett was born. I respectfully asked her permission to continue assisting the birth which she kindly agreed to. So it was at 2.15pm on 21st Decemebr2011 that this midwife, this Mum, received her own granddaughter into the world, this midwife/mum who encouraged her daughter to take her baby into her own hands as she was being born and gently lift her out of the warm water and onto her breast. What an amazing moment! But I was still the midwife as I encouraged Nick to cut the umbilical cord, to physically separate his daughter from the sole care of her mum, symbolically accepting his role as her father in the responsibility of the lifetime care of his daughter. I was still the midwife as I delivered the placenta and assured myself that there was no excessive bleeding, as I checked for tears or injuries. Nothing…. All is well…. Katy stayed in the bath for a while whilst we all stared at Scarlett in amazement as if she was the first baby ever to have been born and that her tiny fingers and toes were like no others and of course she was more beautiful than any other baby ever to have been born! We played with Scarlett as she floated and relaxed in the familiarity of the warm water. I helped Katy to shower and accompanied her to her bed to rest and organized for her a warm cup of tea and something to eat. I kept in my midwife role until Katy was safely and securely tucked up in her bed with little Scarlett nuzzling at her breast. It was then that I so appreciated the presence of the local midwife who took over the rest. She just took over the tidying up, the documentation, administrative stuff and the advice and formalities. It was just what I needed! I could now be Mum! We laughed, we talked and we shared memories of the day. We made lots of telephone calls to all those waiting to hear the good news. We drank cups of tea and we opened the door to the ‘other‘ grandparents. It was a particularly emotional moment for me to see Katy’s little sister (my Fiona) sitting on the bed with Scarlett in her arms and looking and feeling so happy for herself and for Katy. Nick was the calming influence. His relief that all was well that his woman and his daughter were safe was tangible. He was a proud man. I still remember clearly the sight of Katy snuggled up in her own bed with her little daughter Scarlett suckling at her breast. It took me back to how I felt when she was born. The best moment was when it was all over. I was in my own home, in my own bed with the people I most loved in the whole world. My baby, my man and my mum. I want to finish by sharing how Katy and Nick felt about having a Mum/midwife; Thank you for being the best midwife we could ever have had… for giving me the birth I’d always dreamed of, Scarlett the peaceful arrival she deserved and for keeping calm when Nick was struggling too. It was a wonderful experience we will never forget. We have no doubt that you being there made it as easy and as special as it was.

THEN WHAT?

Dec 18th 2011.
It’s cold, it’s icy, but it’s England! Here I am, once again, surrounded by the love of my children and my family. It’s also a very special day for Lucas. Today is his 11th birthday which he is spending in Spain with his papa. I am with Katy and Nick in the north of England and we are all full of excitement as we await not only Christmas but more importantly the birth of their first child! She very cleverly decided to be born around this time so as to assure that her ‘yaya’ from Malawi would be present to help both her and mummy welcome her onto the world. Katy decided very early on in the pregnancy that she would like their daughter to be born in the coziness and comfort of their home. I am excited, calm and confident that it will be a truly beautiful and memorable experience for us all.
It’s been a long time since I last wrote to you all. The past few months have been by far the most difficult that I have experienced since I arrived in Malawi 4 years ago. I will need to explain to you why it’s been so challenging for me.
The shortage of FOREX due to many political reasons, of which I am not going to pass comment, has been the root cause of the problems we are facing in Malawi during this past year which have over time become more and more acute with little hope of improvement. This of course affects all walks of life but I will just focus on how we have been affected at Bwaila and how this has personally reflected in my life.
We started to feel the effects of the fuel crisis early this year. Fuel is the basis of so many areas of our daily life without which it is difficult to function correctly and efficiently. Little wonder so much of the war and power struggles in the world are somehow connected to fuel. Fuel is transport. Fuel is electricity. Fuel is water. Fuel is supplies. Fuel is work. Fuel is leisure. Fuel is food. Fuel is production. Fuel is health. Fuel is not resourced in Malawi. Fuel needs to be imported. Foreign purchases need foreign exchange. Malawi has a Forex crisis.
During the first half of the year we began to notice the shortages of materials and drugs at Bwaila. It became impossible to restock the cupboards in each and every delivery room as our main stock room was half empty as was the central medical stores. It became normal to hear staff shouting out around the ward “ has anyone got any sutures in their room?” or IV fluids, or catheters, or gloves or medication. But we carried on improvising as best we could. The situation became steadily worse and by September was clearly reflecting on the standard of care that we were able to give our mothers and babies. So when situations began to arise whereby the absence of essential medication resulted in loss of lives of our mothers or babies it often became too difficult to handle.
When the mothers blood pressure is dangerously high with the risk of convulsion and subsequent brain damage or death it is essential to administer the appropriate drugs. So if they are just not available…then what? When the mothers are recovering from major surgery and crying out in pain and the most you can offer is a Paracetamol…then what? When the mother is hemorrhaging after the birth of her baby and the life saving injection to contact the uterus and stop the bleeding is not to be found…then what? When a difficult labour needs essential interventions and the materials are scarce…then what? When a woman needs to be brought in from an outlying village or health center due to complications or needs emergency care or when she needs to be transferred to the main hospital unit for intensive care and the ambulance has no fuel…then what? When the patients condition or progress of labour needs to be documented and there is no paper for photocopying …. Then what? When the photocopying machine runs out of ink and there is no money to replace it…then what? When the power is cut and the generator has no fuel so the oxygen concentrators cannot function, the theatre is in darkness…then what?
During the latter part of last year we faced these and other challenges on a daily basis. It wasn’t about lack of obstetric skills, it wasn’t about tired overworked or demotivated staff, it wasn’t about negligent care, it was about an ever increasing lack of support by the government to ensure essential health care.
I remember Alinafe. She was 23 years old and pregnant with her 3rd child. At some stage during her labour in one of our more distant Community Hospitals it all started to go wrong. They decided quickly that she needed a C/section. There was no power and the generator had no diesel so they could not perform the life saving operation so she was referred to Bwaila. The ambulance was called. There was no fuel. By this time the ambulances they has ceased to be given priority in the fuel queues so Alinafe had to wait until morning when fuel could be found to bring her to us. By the time she arrived she had been pushing for hours. The baby had become impacted in her pelvis due to a mal position and try as it might her body could not expel it. We rushed her to theatre but were unable to save either her baby or her uterus. Alinafe lived….but only just.
Continued on 10th Feb 2012.
With each day that passed I found myself becoming less able to cope with the situation and longing for some ‘time out’ some time away from these frustrations and seemingly impossible challenges.
And so I spent 5 weeks in the UK during the Christmas period. Mostly in the north of England being around my 3 elder children but also visiting my mother and my siblings in the South.
My daughter gave birth to her first child, a girl, on 21st December in the comfort of her own home. I ‘Mummed’ and I ‘midwifed’ and was truly astounded and priviledged to be able to share in this wonderful moment that really belonged to Katy and Nick but that I will always form a part of. ( I will publish my reflections on the experience of being a midwife to my own daughter in a later blog.)
Christmas was spent at Katy and Nick’s house with Fiona and Lucas. Alasdair and Laura were in Spain. We then all got together for New Years’ celebrations which were comfortable and cozy. I always appreciate the times when all my 4 children in the one room!
Lucas and I returned to Lilongwe excited and enthusiastic to begin a new year.
Within days we were back into the routine of school and Bwaila, friends and social life.
All is well…………………………….