Waterbirth internship.

Our principle reason for travelling to Iran was to take part in a 4 day Waterbirth workshop. We were asked to prepare short sessions for discussion on the first day on Waterbirth, VBAC and Vaginal breech. This we did! The next three days were to be practical sessions. It did not quite pan out like this.

So the first day we were welcomed into a very comfortable seminar room in a large military hospital. Here we were quickly introduced and then commenced our sessions. Leila introduced the concept of Waterbirth, then Alison was asked to start her one hour session and several hours later I was given the opportunity to give my sessions on VBAC and Vaginal breech. These were largely theoretical and, as we soon learned, were likely to stay that way as the ‘gynaecologists’ were in charge of all births, and keen to promote managed birth, leading to high intervention rates, and leading to the inevitable high Caesarean Section rates.

After a late lunch, the day basically stalled as nothing specific had been planned for the afternoon. The midwives, all very senior midwives, had been promised a demonstration of a Waterbirth, on a labouring woman, and apart from the ethics of this, the practicalities were that there were no suitable women in the labour ward. Once again Alison stepped in with demonstrations of positions using the CUB that we had taken, discussions around optimal cord clamping, baby massage etc etc. She was exhausted by the end of the day.

Alison’s version of events is available here.

On the second day we were directed up to the labour ward. We did not expect that! Alison was in flip flops; my shoes were open toed, and we were both very casually dressed. Felt quite strange. We did get overshoes and hair coverings. The room we were using had been set up with a birthing pool with the intention of observing a Waterbirth. Trouble is it was no bigger than a bath, we had already indicated that we were not getting involved in a situation where loads of people were present in a real clinical situation and there were no suitable labouring women anyway! In retrospect, and if we are asked again, we could organise a great Waterbirth workshop with simulated practice. But the right equipment would need to be available and some warning given so we could prepare ourselves better.

It was all a little mysterious really. I still don’t really know what was expected for these practical days. What they got however was an unexpected bonus in the presence of Alison who had a whole host of skills that the midwives lapped up. Measuring vaginal dilation by abdominal height / the purple line. Hypnobirthing techniques. Perineal massage. There was a little conflict at this point when our hosts suggested practising on consenting women – not something we would ever agree to. This led to discussions about teaching and learning methods. We did agree in the end to quietly observe the care of a labouring woman so we could reflect on midwifery practice, but this proved difficult due to a lack of suitable labouring women! But somehow the four days were filled with the exchange of information although the language barrier, and a difference in definitions of key concepts led to some difficulties in understanding.

What we did learn is that the maternity services are very medicalised. Most, if not all, labouring women’s progress is overseen by the obstetricians, who deliver the baby on the bed, often with an elective episiotomy, frequently inducing/ augmenting labour with syntocinon. There also seems to be two roles for the midwife and we have yet to get to the bottom of the differences. The doula and the midwife. Their definition of doula is definitely not the same as ours as this person cares for the woman in early labour, undertaking fetal and maternal observations, but not VEs or the birth. The one I saw was excellent, encouraging her woman to keep out of bed and follow her body by rotating hips and using a hot pad to relieve pain. But there was also a midwife in the room at times as well as the obstetrician. And no attempt at undisturbed birth. Lights on, door often left open, too many people in the room – I never did learn the outcome of that labour.

However the obstetrician was interested in the concept of using abdominal height as per Alison Fyfe’s teaching as an alternative to VE. I instructed her, and she carried it out and then instructed several of the midwives on the workshop. This indicated a dilatation of 6-7cm. Shortly afterwards the woman indicated she felt a little ‘pushy’ so the obstetrician asked if it was ok to do a VE. This made me smile as I explained that I was not there to tell her how to manage her own patient! On VE she was 6cm and OP!

We also had a discussion as to whether the woman was a suitable candidate for a Waterbirth – she wasn’t of course because she was on syntocinon and I explained this and the importance of endogenous oxytocin etc. I was told afterwards that this obstetrician was anti Waterbirth anyway but she seemed very pleasant and interested to me – across the language barrier.

As the four days came to an end it was apparent the midwives have a huge problem in that the medics are involved in every birth and have little patience. It is also very apparent that there is a need to get back to basics with the midwives and explore the need to encourage the right hormones and the sanctity of the birthing room. Alison and I spoke about all of this often and I still am via social media.

I would like to find out more about midwifery education – one of the midwives commented that the textbooks used are American and medical texts. No wonder they had no idea about some of the non interventionist concepts we kept introducing. I suggested they use Myles instead – I am looking for commission Jayne Marshall if you suddenly get big orders from Iran!

But what was very apparent was the passion and interest of all these midwives to promote physiological birth and everything that comes with it! Wonderful people. I have no idea whether we helped in any meaningful way. I hope so. Things need to change in that country with a 70% C/S rate. The government is financially rewarding units that are decreasing this rate but there is a need for new definitions of roles, and lots of education/ evidence to decrease these rates.

It was a real pleasure sharing those four days with the midwives.

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