Bimala's Story.

Here is Bimala's account of her baby's birth. As you'll read, Bimala worked at Midwifery Society of Nepal (MIDSON) and was incredibly helpful and supportive to me during my first visit to Kathmandu, and during the follow up visits with Royal College of Midwives. She was instrumental in 'looking after' all the volunteers with the GMTP programme. We are all indebted to her for making our visits so relaxed and pleasant.

Bimala shared with us her interest and concern regarding childbirth, and women's issues in general. She is a well educated, well informed, compassionate and incredibly generous woman. With the knowledge she received from the international midwives while working with MIDSON, she set her mind on that 'beautiful birthing room' picture we had described. It saddened me to read her words '...volunteer midwives whom I had worked with during my tenure in Midwifery Society of Nepal had messed it up for me.' But here is a strong woman. She held firmly the belief that her body could birth her baby, and remained questioning of  local protocol versus 'best evidence'.

How many birthing women believe they don't have choices? Or that their bodies are objects for healthcare professionals to do with what they choose? I think a realistic answer to this question would astound us. There is learning to be done, always, for women and care givers worldwide. Bimala has received criticism for bringing the hospital concerned into 'disrepute'. I believe the treatment she received during early labour is, sadly, the norm and widely practiced in Nepal. This birth story could have happened anywhere in Kathmandu. Surely it is helpful to focus less on the 'disrepute' and blaming of an informed mother, and more on improving respectful, evidenced based, woman centered care?

Excuses have been attempted.... No money. Women don't mind. They want a safe birth. It has to be this way. We are too busy. This Is Protocol.

I've listened to the excuses, and provided direction for change. It is slow. There is no justifiable reason for disrespectful care. The next generation are dependent on strong mothers, and we continue to allow...even perpetuate..this abuse. If this isn't okay treatment for your mother, sister, wife, daughter, then it isn't okay.

Thank you, Bimala, for having the strength and conviction to write this account of your little girl's birthday. I hope your message travels far and wide. Blessed be. xxx

My childbirth experience

Bimala Rai

[Hospitals in Nepal do not have the environment, both physically and psycho-socially, suitable for normal births. I had first-hand experience of the abuse of healthcare professionals during my childbirth in one of the reputed hospitals. Apart from unprofessional attitude and behaviour, there was lack of informed consent, client's privacy, therapeutic communication, autonomy for decision making, and respecting client's decision in their practice. Instead of an environment of calmness and happiness to give birth to my first baby, I was distressed and losing confidence in myself. Delivering a live baby seemed to be their only aim. Whether I as a mother would have a wonderful experience giving birth was far far far from their minds. 

Thankfully, because of few nurses, who were expert in normal births and strongly promoted it, I was able to deliver my baby the way I wanted to. They made me realize the importance of strong will and confidence mothers needed to have for normal birth, and of the role midwives played in helping mothers to do so. During 9 months of follow-up, my obstetrician never bothered to mention different exercises, positions, comfort measures that helped in progression of labour which these nurses taught me during 20 hours of my time with them. Follow-up of 9 months with these nurses would have been far better. It is unfortunate that theses nurses who dedicated their life to normal birthing do not have autonomy to practice as independent healthcare provider and do not have the title of ‘Midwife’ in Nepal.] 

I woke up when my water broke around 4:30 in the morning of March 13th. I went to the washroom to check for certain and I saw blood stain in my panty. I was excited, “Yay!!! Finally, the time has come!” No sign of labour pain but another gush of water leak all over my dress. I changed into a new dress and used a sanitary pad. I did not feel like sleeping, so watched music videos on TV and whistled along. I was in a happy mood. At about 7:30 am I woke my husband up and informed him of the incident. We collected our bags that we had prepared for birthing and went to the hospital. My mother-in-law accompanied us as well.

We arrived at the hospital at around 8:15 am. My water kept leaking every couple of minutes. We went to the maternity ward. I was well acquainted with the former Nursing Director of the hospital who was still working there in another department. I gave her a call and told her about my condition. She said she would come visit me.  My husband was not allowed into the ward. It was a bit upsetting but nothing I could do about it. So he waited outside the ward. I was directed to a room with two beds which probably was the ‘Triage Room’. There were about 4-5 person there, no introduction were given but from my experience working as a nurse I deduced that they were a couple of student nurses, one junior nurse and two senior nurses. I gave them previous records of the latest fetus ultrasounds, lab tests, and follow-up with the obstetrician. One of the senior nurses asked me why I was there. “Well, I am pregnant and,” I started to answer her when she interjected in an annoyed tone, “I know you are pregnant, don’t tell me that. Tell me why you have come.” “Not a good start at the hospital to an exciting day,” I thought, a bit upset that she didn’t let me finish first. Calmly, I told her my water had broken, so I had come. She asked me a couple of other questions including my profession. I told her I am a nurse. She asked me to lie down on the bed, inserted a speculum per-vagina and swabbed my leaking fluid for sample. She did not use the curtains to maintain privacy, so my private parts were exposed for all there to see.  Very moment I had a flashback of my conversation with one of the UK Midwife. 
[After observing per vaginal exams done on mothers-to-be without privacy in front of other care providers, the UK midwife had asked the doctor if the mothers were okay with that. The doctor had replied that it was normal in Nepal and that women did not mind. Since, women in UK liked their privacy and as midwife they ensured that, she was curious to know if it was not mandatory in other countries with different cultures. I had replied to her by saying-“Where respect, privacy, confidentiality, informed consent and decision making are concerned, there is no such thing as culture/country context. Period. Women in Nepal cover their body flesh with clothing as much as possible for propriety, how is she okay when Doctor/nurse she has never met before comes in and exposes her most private body parts and stick fingers in? Majority of women in Nepal are not empowered to speak up for their needs and rights. So, though internally they are shocked, disgusted they try to cope with it by mentally establishing the idea that Health care professionals are allowed to do what they do without her consent. So, these pregnant mothers are normalizing unacceptable conduct from Health care professionals which in return is fostering discrimination, disrespect, and acceptance/expectation of low level of care for women in general in Nepal.”]
And here I was in similar situation. I hesitated to ask the nurse to use the curtain. Not because I felt helpless or underpowered to do so, but because I thought my asking her to do so might make her upset that I had pointed out her bad nursing practice, (keeping in mind they knew I am a nurse as well.) They could have taken it in a positive way i.e. mindfully use curtains for privacy in future, or could take it in negative way which was to see me as a threat, preaching to them about their practice throughout my hospital stay. I wanted to focus on giving birth in that hospital and the last thing I wanted was to be viewed as an annoying patient to my healthcare providers. So, I refrained from making any comments. However, whatever the reason was for not commenting, was I normalizing that misconduct by doing so? As someone educated, bold and a health care professional myself was I doing wrong by not speaking up? I had internal conflict. 
After a couple of minutes a doctor came in and asked me why I had come, looked at my previous records and asked me to lie down again. She then inserted her fingers per-vagina. Again, no curtains! I was also thinking that it would have been nice if the doctor had done the per-vaginal examination while the nurse had speculum inserted for swab test. But I was afraid my comment would upset both the nurse and the doctor; so I kept it to myself. Then I felt sharp pain shooting up into my abdomen and felt like peeing while the doctor was doing her examination. After the doctor was done with PV exam, I went to the washroom to pee with that abdominal pain still lingering. When I came out the former Nursing Director had arrived and with a smiling face asked me how I was feeling. It was so nice to see a smiling face in such an occasion.  I greeted her and said, “I was fine but now, for some reason, I have pain in my lower abdomen after the doctor did per vaginal exam on me.” The doctor, writing something on the table beside us looked at the former Nursing Director and said, “Oh! I performed a membrane sweep on her to induce labour!” Again, it was upsetting that the doctor had not informed me about the procedure she was about to perform on me. And again, I held myself back from commenting fearing unpleasant relationship between us, and the internal conflict I had started building up.

Next I was taken to a room with eight beds. It was a bright room. There were three more mothers-to-be, one without IV, one with IV running and one on continuous FHR monitoring machine. The one without IV was crying in pain, looked restless and trying to get out of bed while the nurses were telling her to stop crying and lie down on bed. The other two mothers-to-be were quietly lying on their respective beds. There were same nurses and the doctor from the triage room and another lady in sari and lab coat who was ordering nurses around, assigning beds. I guessed she was the nurse in-charge/supervisor. She did not talk to me.  Not a pleasant atmosphere in the room, at least not for me.  Those international volunteer midwives whom I had worked with during my tenure in Midwifery Society of Nepal had messed it up for me. Influenced by them, I had a wonderful image of a room for my childbirth, image of a quiet room with may be a bed or chair to rest, slow calm music in the background, a birthing ball or other tools for comfortable positions during labour, and only my husband and a midwife in the room for birthing. I had wanted to stay home for birthing but my family were strongly against it, especially my husband. So, there I was in a room full of beds, medical instruments and equipment, little space to walk around, and unhappy mothers-to-be, nurses and doctors who had not talked to me after the triage. I just sat up on the bed assigned to me and watched the activities around me. 

My water was leaking about every 10-15 minutes with slight blood stain but otherwise clear fluid. A nurse came and checked fetal heart rate with a fetoscope. The junior nurse placed IV cannula on my left arm to take blood sample, but left without flushing the blood on the cannula. I called her back and asked her to flush the IV cannula which she said she would. However, she got engaged with another task. So I called the senior nurse and requested her to flush the cannula with sterile saline in case the blood blocked the cannula. She ignored my request and said, “Do not worry. Nothing will happen, we will take care of it if there is a blockage.” This time I could not keep quiet. I would be risking a blocked IV cannula which would mean opening a vein again in another place. So, I kept politely insisting on flushing it right then. The junior nurse saw me talking to the senior nurse, so she came and flushed it. 

It was about 9:30 am when the senior doctor came in for rounds. She came to my bed first and all the nurses and the junior doctor gathered around her. The junior doctor reported to her about my condition. The senior doctor ordered the junior doctor to administer Tab Misoprostol at 10:30 am if I did not get labour contraction by then. I got anxious hearing the order for artificial induction. The senior doctor did not even bother to inform me of it and started walking away. I called after her, “Excuse me doctor. Is it necessary to artificially induce labour now? I want to wait for the labour contractions to start naturally.” “We need to deliver your baby within 24 hours since there is high risk of infection to you and the baby. We cannot wait longer than 6 hours for induction of labour in cases of water break. So, we will wait only until 10:30 am which is 6 hours post your water break.” She replied and walked to the next client. Nope! What I wanted or whether I agreed to their plan for artificial induction was not in their list of priorities since they did not bother asking me or waiting for my reply. 

I had previously read research articles on 24 hour rule for water break and none of them had suggested that it was proven to be the best option. I rushed to the washroom with my mobile and started calling my relatives who had water break before actual labour pain had started. Of the four relatives I called, only one had artificially induced the labour and it was optional. She was given a choice to wait it out or induce labour artificially, in that too which way of artificial induction she wanted. However, all four mothers had delivered without any complications and had perfectly healthy babies. So, I went back to the doctors and so went our conversation in this way: 
Me – “Excuse me doctor. Please let me wait for a couple of hours more, may be till 2-3 pm, for labour contractions to start naturally, keeping close observations on my baby and myself.  If I do not have natural contractions by then, then I will not deny artificial induction.” 
Doctor – “No. We cannot do that. If you wanted to wait, you should have stayed home and not come here. You cannot do as you wish inside the hospital. We have specific protocols here. You have water leaking and with that there can be complications. We want to prevent such complications.”
Me – “I know you are trying to do what you think is right for me. However, I have worked with international midwives before and I have a belief of my own of what is right for me. Not all mothers have labour contractions start within 6 hours of water breaking. There are abundant cases where it started after 24 hours or more post water break and mother-baby turn out fine. There is also no guarantee that artificial inductions will work on me just fine! It has its own risks. I am not asking to wait 24 hours. My vitals are fine, I am not diabetic, fetal heart rate is good, baby is moving, and the water leaking is clear. So, I do not think waiting for a couple of hours more is going to do a lot of damage to the outcome.”
Doctor – “We saw it on your record that you are a nurse. Where did you do your nursing?”
Me – “International University of Business Agriculture and Technology in Bangladesh.”
Doctor – “Is it a Diploma or Bachelor’s Degree?”
Me – “Bachelor Degree.”
Doctor – “Where do you work?”
Me – “I used to work in Helping Hands Community Hospital at Chahabil. I had also worked in Midwifery Society of Nepal (MIDSON) where I was able to learn a lot from the volunteering international midwives regarding normal births. So, I want to have my childbirth through normal delivery. Again, please let me wait only a couple of hours more. I am also ready to sign a risk consent which could state that I had refused artificial induction at so and so time and that the health care providers would not be responsible in case any complications arise later while waiting.”
Doctor – “Look. I know in developed countries they try their best for normal births. However, in Nepal, it is a different context. Every pregnancy is a complication.”
Me – “It is also a normal phenomenon. So, depends on how you perceive it.” 
Doctor – “You are a nurse yourself so you know how it is in the hospitals. We have protocols here that we need to follow. If you want to wait you have to get discharged and go home …”
Me – “Okay then I will get discharged and wait at home.”
Doctor – “However, you have to sign Leave against Medical Advice (LAMA) paper to leave. If you do so, we will not treat you later if you come back with complications.’
Unbelievable!! I would like to believe that the doctor just worded her thoughts wrong and what she actually wanted to mean was that she would not be responsible for the complications later but would treat me nevertheless. I told them that I would leave against the medical advice. 

As I went back to my bed, they called in my mother-in-law and talked to her for couple of minutes. She came to me and said, “The doctors are upset with you. They said they had never seen such arrogant patient before, that you are being unreasonable. They asked me to make you understand.” I told her of my decision. My mother-in-law told me to do what I felt was right for me. 

By then it was 10:30 am. The doctor came to me and said if my cervix was effacing and opening well they would not use the artificial induction. I agreed and allowed them to do a PV exam. After the exam, doctor said that I was only 1.5 cm open which, in her opinion, was not a good progress. She told me it was time for induction, so I better make quick decision. I called the former Nursing Director and told her of my situation. She came and requested the doctors to let me wait for just a couple of hours. However, doctors denied. By this time I was distressed, worried, confused and starting to doubt my decision, whether I was taking risk for my baby as well.  But I strongly felt I could have normal birth without induction since both my baby and I were doing fine. So, I refused induction and signed the LAMA paper. They also needed my guardian to sign the paper (as if I was incompetent of making my own decisions.) I said my husband (who was apparently sent to arrange two pints of blood for surgery) was on his way to the hospital. She wanted my husband to meet her as well. When my husband did arrive, the doctor brought the LAMA paper, handed it to him and simply said, “We have been counselling your wife for the last two hours. Ask her what you need to know and sign it if you decide to leave.” Then she left. I had informed my husband about the incident through telephone on his way back. Poor him! He was in dilemma and asked me what he should do. I told him I would not artificially induce labour yet so we had to leave. With some hesitation he signed the paper. As we were preparing to leave, a lady (I guessed she was Nurse incharge/supervisor for the next shift) came to me and asked politely asked me why I was leaving. When I told her the reason, she did not make comments on my decision but simply warned me of the risks for infection and advised me not to wait too long before going to another facility. I was so grateful for her! Her conduct showed true professionalism of a healthcare provider. Not commenting on my decision showed she respected it, and even though I was no longer in her care she warned me of risks, and advised me of what she thought would help me after I left the hospital. I thanked her for her concern and left the hospital. 

That morning I was confident, happy and excited. By the afternoon, when we were back home, I was worried and anxious, so was my family. But my strong determination and will for normal birth kept me focused. I knew of a birth centre where only normal deliveries were conducted by the expert Skilled Birth Attendants (SBA). It was called Adharbhut Prasuti Sewa Kedra (APS). I was acquainted with the birth centre and the experts there through MIDSON. I called them and informed them that I wanted to have my delivery in their birth centre. They asked me to come to their facility. I informed my family members about it. We took our lunch and went to APS Kendra. 

At 2:30 pm when we reached APS, Miss Amala Maharjan, a nurse with SBA skills and 20 years of experience working in Paropakar Maternity and Women's Hospital, was there to welcome me with a big smile on her face. We greeted each other, I introduced to her my husband and mother-in-law. I gave her the file with all the records of my previous check-ups. I also told her that I had refused artificial induction in the hospital and left it before coming to the birth centre. We discovered that the hospital had given any records or notes regarding the procedures and treatments performed during my stay there. I told her that they had performed PV exam twice and the last cervical opening measured just 1.5 cm. Nevertheless, she wanted to perform a PV exam again for official recording at the birth centre. I agreed and allowed her to do so. The cervix had opened about 3 cm, which was good progress. She said as long as both mother and baby are fine with no meconium staining in the leaking water, we could wait and watch for labour. I was relieved. She took my vital signs, foetal heart rate, and took me to the room where I was to deliver. It had two beds, baby weighing machine, two padded benches, birthing ball, a wooden birthing stool, and a cart with medical supplies for normal delivery. It was quiet in the whole building. There were few student nurses, two staff members and nurse Amala. I was starting to calm down. Nurse Amala asked me to walk around or take rest as I wished. She encouraged me to eat and drink warm fluids since I would need the energy later. So my husband and mother-in-law rested on the bench while I walked around the quiet building. I kept myself hydrated with warm milk, tea, and water. It was exactly what I wanted for my childbirth, a quiet place with my husband and nurse with me. 

At around 4 pm I felt a slight contraction in my lower abdomen. It went away very quickly. I kept walking. The after 20 minutes I had another contraction of same nature. After that I noticed it was coming and going every 25-30 minutes. I was sure then that labour pain had started, almost 12 hours after water break. If I was at the hospital I would have already consented for artificial induction of labour. So, I kept walking. Nurse Amala taught me few positions that helped in the descend of the baby in pelvis. While doing those positions, I chatted with nurse Amala about MIDSON. It was all nice and comfortable. Later, at around 6 pm, nurse Amala brought in an obstetrician who was an outpatient consultant at the birth centre. She reviewed my records and said that we could wait and watch, and left. Mrs Rashmi Rajopadhyay, founder chairperson of the birth centre whom I had known through MIDSON, came in to check on me as well. My mother-in-law went back home as it started getting dark, and my husband brought me dinner from home. After about 11 pm at night my contractions got a bit stronger, but tolerable, and lasted for about 25-35 seconds every 8-10 minutes. Nurse Amala would come to the room every hour to check FHR and my vitals, and reminded me to watch for baby’s movement and colour of the leaking fluid. She also advised considering use of Pitocin in the morning. She would encourage me to eat/drink and rest when possible. She also recorded my contraction at times. I used the wooden birthing stool a lot since it felt comfortable, while squatting could help in the decent of baby’s head in the pelvis. 

It was 10 minutes to 4am in the morning when I had my first intense and long contraction. It came back again after 2-3 minutes and lasted for about 50-60 secs. I called for nurse Amala who came right in and timed the contraction. She said she wanted to check for the progress of cervical opening and effacement which I agreed to. She found that I had effaced 80% but cervical opening was only 4cm. She advised to start me on Pitocin and I agreed to it. I had total confidence in her practice, therefore I did not hesitate to consent to her advices. She hooked up IV Pitocin on my right wrist (since my left was used by the hospital) which did not flow well because I was moving often to ease that intense labour pain. 

What intense pain!!! And how nice that my husband was there to massage my back, support me while I was squatting, or let me squeeze his arm when I was not able to tolerate the pain. He looked at me helplessly but looking at him gave me courage to bear through the pain. Yet, I was getting weaker with each contraction. At times Nurse Amala would remind me to do deep breathing which totally did not work with me. I must have practiced that during prenatal period but I did not have a midwife to inform me that then. I was almost on the verge of giving up after two and a half hours of intense labour when suddenly I had the urge to push the poop out. I told my husband to call nurse Amala who rushed in and found out that it was time. Suddenly, I had this rush of energy in my body. I got up into the bed, was on my hand and knees ready to push with all my might. After four pushes, I gave birth to my baby girl. They put her on my chest while they cut the cord and waited for placenta to come out. I had slight tear on labia minora but otherwise fine. They dried my baby, weighed her (turned out 3.5 kg), wrapped her in warm clothes and gave her to my husband. After they had cleaned me down there, my husband came and gave our daughter to me. 

I had thought, when I first see my baby, whom I had waited to meet for the last 9 months, I will have one of those emotional moments, you know, all teary or feeling super happy/wonderful, like in the movies. Nothing!! I thought she looked like a boy! And not cute at that too! I was not unhappy or anything but I had expected a little more emotion on the first meeting from my side. All I had was feeling of relaxation and relief that intense contractions were over. I took her in my arms and started breastfeeding her. I was advised to continue antibiotics for 5 days and was also counselled on breastfeeding, time for immunizations, Kegel exercises, and nutrition. Nurse Amala came to me and said, “You have a strong will. If you had not been confident and if your family members had not been supportive, we would not have been able to have a normal birth.” Deep down I knew it was true but also the fact that she had played the main role in helping me to stay strong throughout. 

In three hours post-delivery, I was back home with the whole family welcoming my baby. Nurse Amala and Mrs Rashmi Rajopadhyay, and Ms Laxmi Tamang (one of the founders of APS Kendra) kept following up on me and my baby’s condition through phone calls. They wanted to make house visit for follow-up but I did not want to waste their time for nothing. 

Today, my baby is 15 days old! She is doing fine eating, pooping and sleeping at her will while me and my husband have black eye from all those sleepless night which we understand is likely to continue for couple of months more. Oddly instead of being stressed, my husband and I are super happy. And now I find my baby girl to be the cutest of all!

The End