Thursday in Nepal: a day of strikes and signatures

Ruth and Tracy, UK Midwife Volunteers, helping to prepare 300 delegate bags for Nepal's first midwifery conference, being held this weekend and supported by our project.

Me signing three hundred conference certificates of attendance!

Today there was a national strike to protest about the increase in fuel prices.  It was eerily quiet on the roads; no vehicles except emergency services, and very few motorbikes.  Our hotel is on a main road so breakfast seemed so peaceful compared to the usual cacophony of horns, whistles and trucks. No taxis or buses were running so we had a lovely walk to the Midwifery Society Office, about 30 minutes away from the hotel.  It was all hands on deck to prepare for the conference - finishing the programme, signing all the certificates, packing all the delegate bags, and writing speeches.  The MIDSON staff also had a small welcome ceremony for Gillian and I, presenting us with beautiful scarves, a folder of information, and an apple for good luck!  They bought us Momos (savoury dumplings with a spicy sauce) then shortly afterwards also gave us each a takeaway lunch box which was enormous - rice, curries, dahl, spinach, poppadums, chutney, yogurt...   Couldn't possibly eat it all but thankfully the Ruth and Tracy (UK midwife volunteers) arrived back from the maternity hospital in time to help us out!

I had time for a short chat with the Kiran Bajracharya, president of MIDSON, planning the rest of our 10 day visit here and making sure that we set enough sufficient time for everything that needs to be done. 

Tomorrow morning we will go to Tribhuvan University to observe a 'Saving Mother's Lives' workshop on Post Partum Haemorrhage being run by UNFPA before the 2 day midwifery conference starts on Saturday.  The conference is at The Shanker Hotel so we are moving there tomorrow to stay for the rest of our time in Nepal.  I have just looked at the website and realised that we're definitely going up in the world http://www.shankerhotel.com.np/.  This is certainly not the project's usual style but I will enjoy it whilst it lasts!

Still writing speeches and planning evaluation tools so time to sign off for today.  Thanks for following the Blog and lending your support.

Second GMTP Nepal Trip September 2013 - Day One

We arrived in Nepal at 3pm this afternoon and have our first meeting at 6pm.  Little rest for the wicked!  I'm here for the second time in my role as Global Midwifery Advisor to the Royal College of Midwives' Global Midwifery Twinning Project.  I'm travelling with Gillian Smith, Director for the RCM in Scotland.  For this project, Scotland is twinned with Nepal.  Senior Scottish (and some English) midwives volunteer here for periods of 2-4 weeks, helping to grow the midwifery profession and midwives association in Nepal, in addition to the workshops that occur every six months developing different aspects of midwifery regulation, education and association.  Gillian has a crucial role in the project, helping to orientate volunteers and others, supporting the project's activities and relationships, and promoting Nepal and the Twinning Project in Scotland.  I'm delighted she's here with me to see the project for herself and to develop a deeper understanding of the context of midwifery in Nepal.  She is also blogging during this trip so you can follow her at http://midwife4scotland.wordpress.com/

This coming weekend Nepal will be holding its first ever midwifery conference with almost 300 delegates. Gillian and I will be giving a couple of speeches and chairing some sessions, plus doing lots of networking with officials, agencies and key people involved in trying to get midwifery education and regulation off the ground in Nepal.  At present there is no separate midwifery registration or direct entry course and we have been contributing to the effort to establish these as quickly as possible, and to get midwives on the ground, saving lives.  Nepal has been working hard to reduce its maternal mortality rate through training skilled birth attendants (a short crash course in emergency obstetric care) but there is good evidence that midwives are the long term solution http://www.unfpa.org/sowmy/resources/docs/main_report/en_SOWMR_ExecSum.pdf

We also hope to undertake some evaluation of the project at this, the midway point, so we have a busy schedule lined up. My colleague Delicia, our project administrator, is also here with us helping MIDSON (The Midwifery Society of Nepal) to organise the conference  and two UK midwife volunteers are here supporting local midwives alongside us. The Asia Advisor for the International Confederation of Midwives will also be here for a few days - she's an amazing, inspirational midwife from Afghanistan who I met on my first trip here.  We're hoping to have a good time all together but, more importantly, to make a difference.   I will then fly on to Cambodia to do the whole process again, and will be away for a total of 3 weeks. 

Organising a trip like this takes a huge effort.  Aside from the hotel and flight bookings, currency, phone, packing and other resources required, family life in the UK continues as normal.  Dogs need walking, daughter transporting to various activities, meals cooking, church and other commitments covering... and the family needs loving and nurturing.  I am immensely grateful to my wonderful husband Stephen for being such a great Dad to Hannah and for supporting me in my role, but also to our parents, dog walkers, family and friends who help out in various ways, to those who follow and encourage me via Facebook and Blog, colleagues who hold the fort and answer emergencies queries from afar, and those who love, pray and send good wishes.  It wouldn't be possible without you.

Christmas re-visited cake

This is an excellent cake for finishing up any leftovers from when you made and iced your Christmas cake.  It's an adaptation of a recipe for Mincemeat and Marzipan teabread in a BBC Good Food Recipe Book.

Pre-heat oven to 180c.  Line a brownie tin with baking parchment.

Rub 6oz butter into 12 oz self-raising flour.  Add 5oz marzipan, cut into 1/2 inch cubes, and 5oz light brown sugar.  I also added a handful of left-over glace cherries.

Mix together 3 eggs with a standard sized jar of mincemeat (approx 400g) then pour these over the dry ingredients and stir to mix. 

Bake for approx 35 mins or until a skewer comes out clean.

The original recipe suggests covering the cake with flaked almonds prior to baking then dusting with icing sugar whilst still warm - but I wanted to use up 1/2 a packet of left over fondant icing that had gone a bit hard. I zapped it for 30 seconds in the microwave then rolled it between two sheets of clingfilm to fit the top of the cake and covered it whilst still warm.

Cut into squares and enjoy.

 

With woman, with my sister

Midwifing my sister: a deeply profound experience

(Originally published in The Practising Midwife (2006); 9(4):18-9.

In 1993, as a nearly-qualified student midwife, I cared for a friend having her first baby; it was a harrowing experience.  I felt vulnerable as a junior in the NHS hierarchy.  My friend was relying on me to protect her from harm but I felt powerless to do that.  She and I felt traumatised from the birth.  I vowed not to provide midwifery care for a friend or family member again until I could have more influence over the decision-making process.

So when, in 2002, my sister Anne asked me to be her midwife I was rather wary.  At the time, I had been working overseas for several years.  I had only recently returned to midwifery practice in the UK and begun to rebuild my confidence.  Anne lived outside my normal area of practice and I felt uneasy about acting as a midwife in an unfamiliar area.  Initially we planned for me to be a birth partner rather than a midwife.  I encouraged her to book with her local midwives but to use me as a sounding board if she wished.  However, as we talked through her birth plan and the various scenarios that might happen within NHS maternity care, Anne became sure that she wanted me to be her midwife, not just her doula.  She wanted to know the person at her birth that would be helping her to make decisions.  She wanted me as a midwife to protect her and her baby from routine medicalisation.  This was especially important as Anne was having her first baby at 40 and she felt that she might be treated as high-risk by virtue of her age alone.  She felt well prepared for the birth, both physically and mentally, and wanted minimal intervention.

Anne (left), Me (Centre), Esther (Right) - around 1970

Anne felt she would be unable to birth comfortably in her local hospital which had tiny labour rooms and seemed busy and impersonal.  However, her husband felt uncomfortable with the idea of a homebirth.  As a compromise, she decided to have her baby in the unit where I worked, staying with our parents (who live locally) as the birth approached.  I explained to Anne that I could not guarantee being present at the birth, as I was working full-time and also studying for an MSc.  I reserved the right to ask a colleague to take over Anne’s care if at any time I felt awkward or unable to be objective in my professional decision making.  I talked with my supervisor who agreed to support me and signed a vicarious liability form to enable me to work outside of my contracted hours if needed. 

Anne in recent years

As it happened, Anne timed her birth perfectly!  She went into labour at forty one weeks and spent a few hours at a local pottery and later at home, using yoga positions and breathing techniques.  She phoned me just before I went to work for a night shift to tell me that her contractions were getting stronger, although she was coping fine.  I warned my colleagues at work that my sister might be arriving in labour and they were very supportive, making plans to free me up should the need arise.  Anne kept in touch by phone, and finally came into the hospital with her husband at around 0230, contracting strongly every 2 minutes! 

As she walked through the door I could see she was in well-established labour and was coping really well.  She seemed very relaxed and I think the ‘adrenaline rush’ which sometimes accompanies women into hospital and puts their labour “off the boil” did not occur because she knew she was coming to someone who loved her and whom she trusted.

I ran the birth pool as Anne had thought she would like to use water for labour and/or birth.  However, in the event she seemed to get into a rhythm on dry land and did not want or need to get in the water.  She was almost completely silent in labour.  She did not need me to have physical contact, just to be there.  I supplied tissues, bowls and water when she threw up (which she did throughout her labour) and helped her find other comfortable positions when her knees gave way.  She spent most of the time standing leaning over the bed, squatting next to it, or kneeling on the floor.  She used no pain relief, other than a TENS machine.  I sat at the side of the room, quietly reading whilst writing notes which I hoped would not only provide a midwifery record of the birth, but also some sense of the occasion.  I reviewed my note-taking with the midwife in charge every couple of hours to help me maintain a sense of objectivity. 

I had decided to have a second midwife in the room with me for the birth, to give me confidence and to ensure transparency.  However, I learned that not all midwives are comfortable with normal birth in upright positions and labour rooms without monitors!  I noticed that Anne’s rhythm was disturbed when other people entered the room.  I worked hard to maintain a relaxed atmosphere and to protect Anne from unnecessary interventions from others, whilst making sure that I had the back-up I needed.  When the delivery was imminent I called for a second midwife with some reluctance.  To my delight a like-minded colleague entered the room, having just arrived for an early shift.  She did not disrupt the calm, expectant ambience that we had created and was just “there for me” which I really appreciated, not taking over but being appropriately friendly and kind. 

Anne birthed baby Freya beautifully at 0717 in a kneeling position, with little input from me.  As Freya was born Anne said (more to herself than anyone) “I can’t believe it, it was just how I wanted it to be”.  It was the end of my shift so I hand-picked a lovely midwife to take over from me.  We then had some very special family time, making phone calls, Freya nuzzling skin-to-skin and all of us having some good old NHS tea and toast.  The following night my colleagues arranged for me to work on the postnatal ward so that I could continue to care for Anne and Freya.  Anne then went back to my parent’s house for a fortnight of mothering before returning home, breastfeeding beautifully and delighted with her birth experience.  Freya is now three and brings us all a great deal of joy.

Anne has recently given birth to her second baby, Max, at home.  Four months after Freya’s birth, I also helped my sister, Esther,  to have her first baby at home.  Again, it was a wonderful experience for all of us and I have become fascinated with the concept of midwifing friends and family.  Having strangers in attendance at a birth is only a very recent phenomenon.  Less than a hundred years ago, women were almost always midwifed by family members or someone well-known to them; in many parts of the world this is still the norm.    In today’s culture of medicalised birth owned by “the system” rather than by the family, many of my colleagues and friends expressed surprise that I was “allowed” to care for my family members in a professional capacity or that I should want to.  Some found the idea disgusting; others wondered if it is even legal.

Midwifing Anne was a profoundly moving experience.  It felt so natural and right to be looking after her in labour.  It did not feel weird, scary or awkward – I felt very relaxed and had a strong sense that everything would work out fine.  I had faith in Anne’s ability to birth her baby without intervention and I felt immensely proud of her for what she achieved. It has deepened our relationship and I have a very special bond with Freya.    I am not able to birth my own children (though I have an adopted daughter) and being with my sister as she had her baby was strangely comforting. If I had been lucky enough to birth a baby, I like to think that I should have been as strong and brave as my sister was. 

If your sister or friend wants YOU to be her midwife:

• Encourage her to write a birth plan and talk it through with you
• Enlist the support of your supervisor and your colleagues
• Be prepared for some negative comments
• Have a back-up plan for a long or difficult labour
• Be careful about who comes in the room!
• Enjoy it!

My lovely sis with her kids a few years ago

Episode 5 - The Denture Disaster

After my 'booze cruise and bruise' on the children's ward came the placement I had been dreading - eight weeks of geriatric nursing at St. Francis Hospital in Dulwich (http://www.kcl.ac.uk/depsta/iss/archives/collect/1sa40-0.html). Previously a workhouse the hospital struggled to disassociate itself from its history and had a poor reputation amongst the general public, many of whom believed that if  you were admitted there you would never come out, except in a box.  The fact that it specialised in care of the elderly and mental health (at a time when long stays were common for psychiatric patients) did little to shake this belief.   Senior student nurses relished sharing horror stories from the geriatric wards.  I steeled myself for endless hours of heavy lifting, commodes, double incontinence and crusty toenails. 

However, from the moment I arrived on the ward I loved it. Though the work was indeed heavy and tiring, I loved being with older people and often felt sad to leave at the end of a shift.  Both of my grandmothers (separately and at different times) had lived with us throughout my childhood and I found that I knew how to relate to older patients, balancing caring for their needs without removing their independence.  There was a steady ward routine which varied little from day to day, presenting less of a challenge for my dyslexia, and I found immense satisfaction in providing good nursing care and making people comfortable.  Patients often arrived from nursing homes in a terrible state - care homes then were less well regulated than they are today. Sometimes they came from their own homes where they had been just managing on their own until succumbing to an illness and losing the plot completely.  Many times we received confused, agitated and aggressive patients, covered in faeces and lying in wet sheets with bed sores, matted hair and grimy nails - as well as the illness or infection that had brought them into hospital.  The transformation was often remarkable once patients had a few days of antibiotics, good nutrition, attention to their personal hygiene and compassionate care and companionship.  The hospital hairdresser and the barber visited the wards regularly - I also became adept at the shampoo and set having watched my mother do this for my grandmother countless times.  Sister frequently whipped round the ward with her razor, militantly getting rid of the old ladies' whiskers!  A new hair-do and the knowledge that they no longer had to cope alone restored some dignity and humanity to our patients and the person that they had been (and still were inside) began to shine through. 

Many patients wore dentures (false teeth) which were kept in dedicated pots on their bedside table.  Cleaning dentures was a gruesome and time-consuming business but an essential part of the morning routine when helping patients to wash and dress. In the small hours one night shift, needing an activity to keep me awake, I decided to collect all the dentures from patients' lockers and wash them, lightening the load a little for staff on the early shift.  Before I had thought this through carefully I  tipped all of the dentures from all of the pots into the sink and set about scrubbing them. It slowly dawned on me with a terrible sinking feeling that I had no idea whose dentures were whose, and which ones fitted together.  It took the best part of a week, and much trial and error, to reunite every denture with its pair, and every pair with its owner! Thankfully sister was kind to me and appreciated that I had the best intentions, even if my actions were somewhat misguided at times.

The ward sister was young and dynamic and ran the ward with military precision, insisting on high standards of care and hard work from her staff. She had a tough job as many of the qualified staff were agency nurses. Some were critical of the sister, saying she had progressed quickly up the hospital hierarchy only because of the unpopularity of geriatric nursing but I learned much from her and from my placement on the ward. I learned, as would learn time and again, not to pay attention to others' opinions of staff or placement area before making my own judgements.

Although many patients responded to treatment, death was also fairly common on the ward and most patients had 'do not resuscitate' orders in their notes. The cardiac arrest team had to come from Dulwich Hospital, separated by a foot tunnel under the railway, so such calls were not often made!  I remember a patient named Aggie who died gently one day whilst talking to the patient in the opposite bed.  When her neighbour realised she was having a one-way conversation she called me over in a piercing voice saying 'Nurse!  I think she's DEAD!' I summoned the ward sister who quietly drew the curtains round the bed and decided not to call for assistance.  Some may have disagreed with her decision, but it was a death with dignity and her family appreciated that no one jumped up and down on her chest at the end of her life.

During the placement I was also studying for my end of year exam which involved learning by heart Virginia Henderson's 'Nine Activities of Daily Living' with the aid of a mnemonic that I can't remember now - only that it was something to do with an elephant! Wikipedia has refreshed my memory of those activities: maintaining a safe environment, communication, breathing, eating and drinking, elimination, washing and dressing, controlling temperature, mobilisation, working and playing, expressing sexuality, sleeping, death and dying.  We based patients' care plans on these activities though working out how old ladies in the geriatric ward could express their sexuality was always a difficult one!

These activities also provided a structure for answers to exam questions. Despite the denture episode I passed the placement with flying colours and passed my exam, progressing into the second year and receiving a maroon belt to match my frilly hat.  That summer I moved out of the Nurses' Home at St. Francis hospital into an attic room at no. 88 Herne Hill, a huge old house shared with 6 phsyiotherapy students and began one of the happiest times of my life.  Those stories will have to wait for the next episode...

Curried Sweet Potato and Red Lentil Soup (Adapted from Hugh Fearley-Whittingstall’s Veg Book to be Slimming World Friendly!)

Spray a large heavy saucepan with frylight.  Chop 2 onions, 3 cloves garlic, a large knob of peeled and grated fresh root ginger and 1 fresh red chilli.  Sweat these down in the pan on a medium heat, adding a few tablespoons of water as the mixture dries out.  Add in 1 tbsp ground coriander and 2 tsp curry powder.  Cook for another 2-3 mins, adding a small amount of water if too dry.

Meanwhile, peel 3 large or 5 smaller sweet potatoes and cut into cubes of about 1 inch.  Add the sweet potatoes to the onion mixture and 1 teacupful of Red Lentils.  Stir for a few minutes to coat in the spices, then add about 1 litre of water and 2 tbsp Marigold Veg stock powder (or stock cubes – or use fresh stock if you have any).  Grind in some black pepper, bring to the boil then simmer on a low heat for approx 30 mins until the potatoes and the lentils are soft.  Add salt to taste after cooking (apparently if you add salt to beans or lentils before cooking they become tough!)

(The original version uses olive oil to sweat the onions, and a can of coconut milk at the end with some lime juice).

Blend the soup once it’s cooked, and serve with a generous dollop of low fat yogurt and lots of chopped fresh coriander or watercress.

Walk the dog Mulligatawny Soup

A recipe for a low-fat tasty soup that cooks itself whilst you walk the dog.

Chop an onion and 1 clove of garlic and grate a 'thumb' of ginger. Sweat in a pan with some fry-light (spray oil) adding a few drops of water if it gets too dry.  Add the following spices (or just use curry powder if you're feeling lazy): 1/2 tsp cinnamon, 1/2 tsp turmeric, 1 tsp ground coriander, 1/2 tsp group cumin, 1/2 tsp chilli powder, pinch ground cloves. 1 bay leaf or curry leaf.  Cook for a couple of minutes, adding a little more water if sticking to the bottom.  Add 1 cup red lentils, 3 chopped carrots (no need to peel), 3 chopped potatoes, 1 chopped apple, 1 tin chopped tomatoes, 1 pint water and 1 veg stock cube (or Marigold stock powder).  Bring to the boil, put in the oven at 160c and walk the dog for an hour.  If you're planning a longer walk, cook it at a lower heat!

Blend it if you like (or leave it if you prefer chunky) and serve with a dollop of low fat yogurt and chopped fresh coriander.