Midwifery Refresher and Respectful Care Update Course

April 19th and 20th we helped Cathy and Micky, facilitate the Midwifery Refresher Course for nurses from Dhaulagiri Zonal Hospital and newly trained SBAs (skilled birth attendants) from rural and remote areas of Nepal. Two MIDSON trainers, Amala and Asha, were also facilitating as well as the departing head nurse and one of the SBA trainers. It was great to have a local expert, Debi teach the condom tapenade, a life saving procedure that can be used to treat Post Partum Haemorrhages that are unresponsive to medications. This is similar to the bakri balloon that can be used in the same circumstances.

The condom tapenade station. 

The topics covered in the course were:

• Respectful childbirth
• Slow delivery of the head
• How to use the somersault maneuver for a nuchal cord
• Comfort measures and positions for labour and delivery
• Breech delivery
• PPH
• Hypertension
• Pre-eclampsia
• Condom Tapenade
• MVA (Manual Vacum Aspiration for incomplete miscarriage, retained products postpartum and comprehensive abortion care)
• Helping Babies Breathe
• Immediate care of the newborn emphasizing skin to skin and breastfeeding in first hour

On the morning of the second day, two of the nurses shared with us that they conducted two deliveries last night using slow delivery of the head with no tears. They were so happy and giddy while explaining the two births to us. This is so exciting to us because it is still routine to give all women an episiotomy during childbirth, especially nulliparous women. We are hopeful that these three young nurses will change the face of care in their hospital.

There was time on both days for presentations on respectful treatment of women in general and also in the childbearing years.

The respectful childbirth presentation by MIDSON was especially important as in Nepal women have few choices during childbirth. For example they are not given the option to have a labour companion or partner in the delivery room or choice of positions. Stories abound in Nepal of women being physically and verbally abused during childbirth.

The nurses and SBAs were keen participants. We enjoyed laughing and learning together with them.
We taught slow delivery of the head, comfort measures and positions for labour and delivery, how to use the somersault maneuver for a nuchal cord, and Immediate care of the newborn emphasizing skin to skin and breastfeeding in first hour. By the end of the day the two of us had birthed dozens of babies through our birthing pants!

Mickey and Cathy presented each of the SBA's with the book "Where Women Have No Doctor" in the Nepali language. This book has been translated into many languages and given to people providing care to women all over the world with limited resources. These books are written by the Hisperian Foundation. To learn more check out their website: http://hesperian.org/

We wrapped up the two day workshop with a short little dance party and photoshoot. We played the song Sisters by a Tribe Called Red and invited the participants to dance with us. This song was chosen by the Canadian Association of Midwives as the song to dance to this year on International Day of the Midwife, on May 5th.

The SBA's and nurses wrote these ideas about respectful childbirth. 

Babies in Baglung

Babies in Baglung

We arrived in Baglung on Friday Feb. 13th by jeep from Pokhara. We first had to fly from Kathmandu to Pokhara. The journey in the jeep was a very scenic adventure up into the mountains along a partially completed road. 

We are working at Dhaulagiri Zonal Hospital, a public hospital in Baglung that serves a population of about 60,000, in addition to the surrounding villages. The head nurse of the hospital is a woman with a Bachelor of Nursing who will be leaving for Kathmandu soon to complete her Masters of Public Health. She has been working and collaborating with Cathy and UBC for several years. Her knowledge of the culture, health care system, and translation skills are invaluable.  Auxillary nurses are the ones working the maternity ward. Some but not all have Skilled Birth Attendant (SBA) training. The ward is also buzzing with 6-10 nursing students each shift, and 2 or more SBA students. The nursing students are very young, around 18-19yrs old. It can be quite overwhelming to have everyone in the room during delivery, but it is also wonderful to have so many hands and skills. 

Mount Dhaulagiri from the roof of our hotel

Day 1

We had an interesting first day on the ward. Cathy asked us to set some goals for ourselves and the list below is what Emma and I decided on:

• Learn how to document in WHO Modified Partograph

• Using the fetoscope
• getting to know the staff 
• learning some Nepali words and short sentences
• Learning how to apply clorhexadine to the umbilical cord

At 10 am a woman arrived in labour. She was pregnant with her 8th baby. We were surprised to learn that having many children is something that is frowned upon here. Nepal has worked hard to encourage family planning and many families are choosing to have only two children. However women from rural and remote areas, and/or women living in poverty are more likely to have more children as they may not have access to or information about family planning methods. This mother gave birth quickly and easily to a baby girl. The baby was born on the Nepali New Year and in the caul [in the sac of waters] both which are lucky events.

The maternity ward has two beds in the entry hall for women who are not yet in active labour. There are three beds in the ward room for women who are in active labour, being assessed, or being induced. A partition divides the ward room in half. On the other side or the partition is the delivery room. There are two metal delivery tables in the delivery room. There is also a warmer and cupboards with the supplies needed for birth.

Emma and I worked hard to hone our fetoscope skills. We are learning how to listen for the fetal heart rate with a great deal of background noise. Our ears are getting better every day.

Day 2

The morning was busy with women from Baglung and surrounding villages arriving for antenatal check-ups. Some were post-dates, others were in pre-labour. It was a great opportunity to practice our fetoscope skills and palpation skills, in addition to learning some of the hospital protocols.


After lunch we spent time practicing Nepali with the nursing students. We had just finished joking about how we would love a woman to arrive at 8cm, when voila, a woman arrived fully dilated. Continuing with some of the teaching about labour support we had done the first day, we worked with the student nurses to provide kind labour support. The nursing students helped us to comfort the client through Nepali phrases such as: ramro garnu bahyo ("you are doing well") and lamo sas phernus ("breathe deeply").

As we assessed her it became clear that her contractions were not adequate enough for pushing. After augmenting her contractions with a little bit of oxytocin she easily delivered a healthy 2.75kg baby boy. The babies are much smaller on average than babies in Canada. The average birth weight in Nepal is about 2.8kg, and the average birth weight in Canada is 3.4kg. Similarly, people here are smaller on average than people in Canada. The women here are so incredibly strong, with no pharmaceutical options for pain relief, they easily and courageously push their babies out.

Day 3:

Our Goals for Day 3:

• Deliver babies using slow delivery of the head
• Site IVs
• Discuss cases in terms of how we managed them here and how we would manage them in Canada.
• Continue to practice our Nepali.
• Prepare handouts for Midwifery Refresher and Respectful Care update course April 19 and 20th

We arrived on the ward at 9 am. We discovered that two women had given birth in the night and early morning. We checked on the baby that Emma delivered the day before. Both mom and babe were doing well. We practiced our Nepali with the nursing students who have been very helpful in many ways: showing us how to wash the cord with clorahexadine, how to hang an IV, translating for us, and teaching us more Nepali words and phrases to use with the women.

A young nulliparous (first pregnancy) woman arrived at 10. She had been seen earlier and was 4 cm dilated and appeared to be in active labour. We introduced ourselves and read her chart.

She had a number of women with her who we discovered were her relatives. They were doing such a great job providing labour support. She was very shy and preferred labouring in the stairwell because it provided her with  more privacy. She would come back to the maternity ward so we could check the fetal heart rate. According to the partograph her labour was not progressing quickly enough so the decision was made to augment her labour with IV oxytocin. Her labour progressed rapidly and she gave birth to a healthy baby boy. Cathy supported Jenny through slow delivery of the head.

It was so quiet in the delivery room as she pushed. There were a number of nursing students in addition to Cathy, myself and Emma, and the nurse and everyone was very respectful and quiet. It was a nice change from my first birth where there was lots of background noise and chatter. I think we were able to effectively model respectful childbirth practices.

We walked her over to the postpartum ward with her baby and helped her with breastfeeding.

Dhaulagiri Zonal Hospital

A second young nulliparous woman presented on the ward at about 16:00 in active labour. She too was supported by a number of women. It was so lovely to see how well supported she was. Her labour progressed quickly and soon she was pushing gently. In Nepal they anticipate birth of the baby within one hour of pushing. If a woman has been pushing for more than one hour the nurses consult with the doctor as it is considered a delayed second stage of labour. We consulted with the doctor and he came in. He was very lovely and agreed that she was having a delayed second stage and that we should get baby out but he encouraged us to continue what we were doing and told Cathy he was just here "to support us [the whole team]." The woman gave birth to a heathy baby and Emma caught her second baby in Nepal. We got mom and baby settled in the postpartum ward and went home for dinner. It was a long but good day.

Parpopakar Maternity and Women's Hospital

Today we went for a tour at Parpopakar Maternity and Women's Hospital (Thapathali Maternity Hospital) in Kathmandu. It is the only public national referral hospital in Nepal. The hospital was severely damaged in the earthquake and the matrons were quick to point out that the wards they were showing us are only temporary until the new hospital building is finished. Funding for the new hospital campus has come from jhpiego.

In our new Kurti uniforms in front of Patan Dokha near our hotel. 

We did not take any pictures in the hospital, as we wanted to respect the women's privacy.

We had tea with the matrons and read the hospital report from 2016.  Then they took us to see the midwife-led birth centre. They have worked hard to implement protecting birthing women's privacy by hanging curtains around the cubicles in which the women give birth. There are 4 cubicles in the room. The midwives also work to encourage the husbands to accompany their wives and to provide comfort measures. If the husband cannot or does not want to be there then the woman can bring her mother, mother-in-law, or another companion.

We had the opportunity to see their record book where they enter all of the information about each women birthing that day. It was interesting to see that the average newborn weight was about 2800g. Their PPH rate is also very low because each woman is given 10 IU of oxytocin when the baby is born. Unlike in Canada, episiotomies are performed on most of the women. We briefly discussed avoiding episiotomy by promoting slow delivery of the head but it takes a long time for practice standards to change as we well know.

We also went to the nurse-led birthing unit. A woman had just delivered twins vaginally. The baby girls weighed 2400g and 2700g. All three were well. We were introduced to some nursing students who were 15-17 years old.

We continued on to the post-natal ward for post-cesarean recovery. The women stay in the ward for 4-5 days. There were 20 beds in each ward room. There is no separation between beds so little privacy. What we noticed was that  the women were from many different ethnic groups, due to this being a public referral centre. The rooms were very colourful as the women bring their own blankets for their stay.

We stopped briefly at the antenatal clinic and were introduced to some midwifery students but we chose not to observe as we wanted to respect the privacy of the women as well as the students.

Our overall impression was that the wards were clean and well organized. The midwives and nurses were very keen to show us their equipment and set up. They do a lot with much less than we are used to in BC hospitals.

Namo Buddha

Saturday we took a rest day and arranged to go to Namo Buddha, a sacred buddhist site and monastery about 40 km from Patan. We arranged for Tony to drive us there and for Khadga, a local guide, to accompany us.

We left early in the morning to avoid the "the rush" or morning traffic. It still took us 2 hours to drive there. It was a nice treat to get out of the city and into the fresher air of the hills.

It was raining as we left Kathmandu but it soon cleared up. We drove past the newly erected 144 foot tall statue of Shiva. You can see it in the photo below.

Once we got to the original shrine we stopped for milk tea or dudh chai. The woman also sold homemade wine.

The stupa is beautiful.

After we spun the prayer wheels we walked up the steep steps to the monastery.

It was a bit hazy at the top but still stunning.

We saw the cave where Buddha in his previous form is said to have sacrificed his flesh to feed a starving tiger and her cubs.

We left the monastery and walked down to meet Tony. It was lovely to see the countryside. Along the way we came across a large family picnic. The women were dancing together as we walked by. They insisted we join them and we did. We had so much fun!

Durbar Square by day - April 6

Last week Cathy needed to go get her licence to be in Nepal so Emma and I enjoyed a long breakfast on the rooftop terrace at Tajaa Pha. We had an interesting discussion with Anita from the UK about world politics. Then we went back to Durbar Square to see it in the day light. We are getting braver walking the crowed, narrow streets.

Patan's Durbar Square was damaged during the earthquake in 2015 but not as heavily as Kathmandu's. Many of the temples are being restored and are closed to the public.

During the day you have to pay to enter Durbar Square. We were able to show our visas and get a pass so we can come and go as much as we want to.

We spent most of our time in the Patan Museum. We enjoyed learning more about the different gods and goddesses.

Oh the momos!

When preparing for our trip to Nepal both Emma and I started taking probiotics to help built our gut health. We also visited the Travel Clinic and were given a prescription for Azithromycin Dehydrate for Traveller's Diarrhea.

We also bought water purification tablets as the tap water in Nepal is not safe to drink for us or the Nepali people. They boil the water before drinking it. We boil it and the add the water purification tablets.

Despite choosing to be very cautious we are both keen to try some Nepali foods. Cathy warned us to avoid eating fresh greens and choose foods that have been made fresh and that are served hot. She is familiar with a number of restaurants close to our hotel so we have been trying different things.

Oh the momos! Momos are steamed dumplings filled with chicken, "veg", or "buff". You get 6-8 on a plate and can pour sauce over them. They are very yummy.

We have also eaten chicken Thukpa which is a chicken soup with thick noodles. The broth is so tasty.

For breakfast we eat yogurt and musli with a banana. We can eat fruit if it can be peeled. I was so excited to buy some oranges to eat.

There is a tourist cafe just down the way from Tajaa Pha that serves delicious cakes and coffee. They have a really nice garden patio that we enjoy sitting in. There is a bookstore with a large selection of English books in it joining the cafe. It is nice to browse through the books on Nepal.

MIDSON

Last week we met with Kiran the president of MIDSON, The Midwives Association of Nepal. We were welcomed very warmly. She showed us a presentation of midwifery in Nepal and asked us to help them draft an midwifery advocacy presentation that they will take to all of the stakeholders when working to implement midwifery services throughout Nepal.

They are also interested in creating midwifery-led group antenatal care here in Kathmandu so we are creating an information package for them. When we get back from Baglung we will meet with them again and present our package and role play a group antenatal visit for them.

They are working very hard to get midwifery education up to ICM standards in Nepal. Additionally the are working to create a plan for the implementation of midwife-led birth centres in more communities.

On the whiteboard we saw the list of committees for International Day of the Midwife on May 5th.

Kurtis and Women's Rights

Kurtis and Women’s Rights

Waking up for the second day here in Patan was amazing.
The mornings are so lively with people out and
about conducting their prayers or walking to the early
morning market to purchase groceries for the day.
Like most of Kathmandu, the neighbourhood we are staying
in has a beautiful mix of both Buddhist and
Hindu temples and places of worship.

Purchasing cloth for our kurtis was the main goal of the day.
The traditional tunic dress worn by Nepali women is called the
Kurta. It is worn with matching pants that are either tight, or
loose (punjabi style). A scarf is usually matched to complete the
gorgeous, usually colourful outfit. Each year Cathy helps the
midwifery students to get Kurtis made to be worn as uniforms in
the hospital. Wearing the local clothing, especially when working
in the hospital helps to nurture our relationship with the local women
and the other health care providers. The community driver,
Tony picked us up and drove us to his favourite cloth shop, where
he purchases cloth for his wife, Bina, a seamstress to use in their shop.
We were lucky enough to choose between dozens of gorgeous patterns of cotton fabric.

After Bina took our measurements and we made a plan for our uniform kurtis,
we left to meet up with a local nurse and researcher who Cathy has worked very
closely with. We met at a coffee shop that caters to tourists. We really like it there
as it has a gorgeous patio decorated with flowers in terra cotta pots and
serves great coffee. Bimala brought her two year old daughter, Nina who
happily ate spoon fulls of ice cream in between telling her Aama (mother) to stop talking.
She discussed the current issues that are facing women in the country today,
primarily focusing on childbirth. Her passion and dedication to women’s rights really
shined through. She was kind enough to share with us her own childbirth
experience as an example of the many barriers and problems that face women
during their childbearing years.

Some of the important facts she shared with us include:

• 80% of people in Nepal live in rural communities.
• 20% of people live in urban communities
• Cesarean section rates are very high in urban areas. Some hospitals have a near 100% cesarean section rate. 
• Women have little power over their bodies. For example when a women has a cesarean delivery it is a family member such as her husband or mother in law who signs the consent form. And when it is time for her to leave the hospital, she cannot leave without a family member signing her out. 

 Stay tuned for pictures of us in our new kurtis!