A holiday and goodbyes...

So am sat writing this back in the UK after a busy few weeks. Spent a delightful night at the Hyatt hotel (a present from Anna for my birthday), in which we guzzled all the free food, swam in the pool and luxuriated in the constant supply of hot water (3 showers and a bath in 24 hours). After spending the day round the pool we went to collect Ben from the airport, a task I enlivened by leaving first my swimming costume, then my cardigan and then my swimming costume (again!) at the hotel. The next few days we spent a little time pottering about Patan and Kathmandu, introducing Ben to the friends I had made and taking a little trip to the birth centre. One of the nurses made me chuckle by looking at Ben and then saying furtively "dating?" and when I responded in the affirmative gave me a hi five. We had a lovely dinner with Rashmi and a few of the rest of the senior staff in which both me and Ben were presented with little presents, so characteristic of the generosity and warmth I have experienced from so many people during my stay.

It was then off to Pokhara and trekking for 4 days which was awesome. We followed the established route of taxi to Nayapul, then trekking from Nayapul to Ulleri, Ulleri to Ghorepani, Ghorepani to Tadopani, Tadopani to Kimche, then a jeep back to Nayapul. It was a beautiful route and we had the full range of weather conditions making us, as brits, feel very at home. We were lucky to have enough good weather to see the mountains for the first couple of the days though, getting a stunning vista at Ghorepani. The last two days we mainly surveyed clouds of swirling white mist, accompanied by the ever present backdrop of "Ah on a clear day the views are magnificent!" Well yes.

View from Ulleri

On the way to Ghorepani

Annapurna range at Ghorepani on an exceptionally clear day.

View from Poonhill :-)

Steps! Lots and lots of steps.

Resting at Tadopani

Back to Pokhara for a day recovering and then off rafting with Paddle Nepal. Very enjoyable and a nice way to travel down the country, I relished the opportunity to spend some time in the water,  something I very much missed in Kathmandhu. Not that you want to spend too much time considering the quality of the water of course, something Ben failed to understand, saying enthusiastically at the start "Lets get in this open sewer!"

Camping on the beach. Probably the most uncomfortable camping experience ever but very pretty.

After finishing the rafting we got a bus to Chitwan where we spent 3 nights at the lovely Sapana Village Lodge which really was a haven after the noise and bustle of both Kathmandu and Pokhara. A fantastic place to hang out and just watch the huge numbers of birds flitting about.We did manage to muster the energy to go on a rather nice jeep safari though and a cycle to 20,000 lake taking in the local area.

Relaxing at the lodge

On safari!

I spy...

... a rhino!

It was then back to Kathmandhu for a few rushed goodbyes including hopeful intentions to return. It was lovely meeting up with Rashmi one last time, she has been a pleasure to get to know - passionate, knowledgeable and always ready to giggle hysterically at a moments notice. I shall miss Nepal, with its tasty massala tea, ubiquitous dogs, crazy traffic and surprisingly relaxed vibe. Perhaps I'll be back.

My kurta, a combined present from Emma and Shared who bought the material and Rashmi who had it made. Next time I get invited to a Nepali wedding I will be sorted!

Small and beautiful

Interesting day on Thursday meeting Kirsten, a midwife who works for UNFPA. Sat on the roof of her office block eating dahl bhat, admiring the views and chatted about maternity care and the status of midwifery in Nepal. She said that facilitating change was extremely difficult and despite attempts over the years to start a proper midwifery course it had never really had much sustained success. It seems that there is a lot of money washing around but not enough of it is going to the right places. Some article in the Himalayan Times estimated there are over 38, 000 NGO's working in Nepal. She surprised me by saying that if she came back again she would be tempted to "come in a window rather than going through the door", suggesting the value of working "small and beautiful" on smaller scale projects.

It was interesting because on the face of it I would have thought that working at a policy level with the most influential people in Nepal would be the best way to ensure the most far reaching and large scale impact. It seems that this is unfortunately not always the case within the context of current levels of government corruption and dysfunction. How best then to contribute as a midwife in Nepal? According to Kirsten, to just be a midwife in Nepal. In her view this was important in helping promote the value of good maternity care, increase the status of the profession and where possible model good practice. 

This was admittedly nice to hear as my thoughts about my own activities have varied, sometimes pondering whether it was at all pointful doing something on such a small scale. I have also thought a lot about charity and how best you can really contribute. It often seems hard to know, with much written about NGO's and how they can sometimes do more harm than good.   However, I have realised more as I have gone along that my primary role, on this trip a least, besides the odd bit of training here and there, seems to be to act as a walking mascot for midwifery.When at times I feel a need to Achieve Things,  it has helped to return to my aims for being here which was primarily to learn and experience and only secondly to try and be of some use while doing so.

More training and another baby!

So yesterday turned up to do another training day for the rest of the staff - typical pattern, meant to start at 10, turns out everyone apart from me thought it was 11 and then we started at 11.30 :-) I didn't want to do it all in one day again as it really is a bit too much but there was no other time to do it. This group had better English and were generally a bit more experienced, at least on some subjects, so in many ways it was slightly easier. Amala, a senior nurse-midwife with 20 years experience was on hand all day to translate difficult bits and help with the role plays in which she came into her own - her acting skills were extremely good and had all the girls laughing!

Discussing PPH

PPH role play

Brain storming shoulder dystocia

Role play neonatal resucitation

Practising neonatal resuscitation

Good head position!

The obligatory end of the day photo's... seriously there are hundreds...

All through the training a young woman was in the birthing room in early labour, being looked after by the staff on duty. This was her second baby but was only contracting 1:10, mild to palpate, so I popped in from time to time to see if she was ok and make sure she was eating and drinking. I couldn't help comparing the difference between this woman and those at the hospital as she spent the day walking round the room and intermittently resting, supported by her husband. Later the whole family came by and brought her food. When I left in the evening she was thinking of going home as she had not become established and contractions were the same but when I rang this morning she had had a lovely normal delivery of a baby boy. I felt very happy to think that she had experienced a nice delivery, close to her home with no complications.

A good paint job!

So returned to the birth centre to check out the paint job and was really pleased with the result. Considering the plaster work was not exactly brilliant it looks much better than expected. Would really like to do some of the other rooms really but that might be for next time.

Would be nice to straighten those pictures, get rid of the broken light fitting and add a lampshade but hey ho :-)

Elderley and differentlyable...

So a busy few days. After a week of trying to find a painter who was free and fairly short notice,  Shanta (pronounced Santa, which really never ceases to be pleasing) the local handy man, rang to say he had finally found a painter who was free today to look at the birth centre. A day of going back and forth on his motorbike to meet the painter, get paint/materials and clean the place in preparation and then back the next day to check the painting was all going well. I haven't seen the finished job yet as I had promised Anna a day out on the Saturday and have been feeling a bit unwell so fingers crossed it looks ok!

Off to the cinema in the evening to see the one western film on,  Monuments Men, which was entirely similar to going to the cinema in the UK apart from the fact that every time somebody was depicted smoking the message 'SMOKING IS INJURIOUS TO YOUR HEALTH' came up at the bottom of the screen. There was also the interval, at which point the film was abruptly terminated and we were treated to adverts for steel, paint and hair products. As it was a rather slow film anyway this interruption did nothing to aid concentration. :-)

The next day I was feeling decidedly worse so me and Anna got a taxi to 1905 - farmers market and expat heaven - where I bought an indecent amount of tea and ate a range of yummy food in the sunshine. Following this strenuous activity we went to Garden of Dreams where we did what we do best - napping in the sunshine. An oasis of green in the middle of city, Garden of Dreams was originally built as a private garden in 1920 but was restored in cooperation with the Austrian govenment and opened to the public between 2000-2007. It appears to be a hang out for Nepali couples, made notable by the fact that I have hardly ever seen couples together in Kathmandu. After interrupting their romantic seclusion by taking a turn around the gardens we sat on the mats (which are provided free of charge), read our books and watched a toddler do her best to drown herself in the water feature. Following an impressive and dramatic face plant into the water her mum took off all her clothes and she sat naked in the sun to dry off, at which point a group of teenagers delightedly took photo's. The attitude towards children in Nepal and Thailand appears different to the UK as in both places I have seen locals take photos of other peoples kids without reserve. In a way its rather nice as you realise what negative connotations frame our interactions with children in the UK. Not without reason of course but nevertheless to observe such innocent enjoyment of the children felt refreshing.

We finished our day out with a trip to the Narayanhity Royal Palace where the late Royal family lived until the mass shootings in 2001. 1960's/70's glamour presides alongside occasional Nepali style opulence but the overall style is fairly muted by western standards. Lest you become weary on your way round there are seating areas signed 'Elderley and differentlyable'. As you get to the end of the tour there are signs saying 'Way to the massacre site' and guides you to the area where the shootings took place. The entire building was demolished following the shootings with printed signs showing where each member was shot, leaving me feeling uncertain as to whether it was embarrassingly crude and voyeuristic or eerily respectful. Interestingly, many nepali's are sceptical of the official story that Prince Dipendra carried out the killings with rumours of conspiracy theories involving the Indian intelligence agency or American CIA. There has also been speculation that King Gyanendra was involved in the murders so that he could assume the throne himself.

A.P.S Training Day

So on Monday Rashmi suddenly managed to organise the staff for a training day today. It went ahead seamlessly. Two of the midwives who had been involved in the planning were no longer available to attend which left myself and one other midwife. Then last night a banda (strike) was announced and this morning Rashmi called to say none of the girls could attend so we had to cancel. At half past ten she called again to say all the girls had turned up and could we do it anyway. I tried to call the other midwife who could speak nepali but could not get through so went on ahead to the birth centre on my own and Rashmi came along a bit later.

It was by no means perfect. It was too long. I had known this before but as it had been so difficult to arrange the time off for the girls I decided to include more than was ideal. Doing it in English was also not ideal though Rashmi was on hand to translate complicated sections. The girls had quite a variation of experience with some having very little knowledge at all and others having a good grasp of the basics which made it slightly harder to pitch.

But it was good fun! I tried to keep it fairly simple but convey the main points and tried really hard to ensure they had understood and were not just nodding along out of politeness. I started each section with them brainstorming as a group everything they knew about the subject to give me some idea of what level to pitch it. I then went over the theory and followed with practical role plays. It was exhausting but fun, the girls did really well concentrating for so long and laughed a lot at me demonstrating the knee chest position and practicing the McRoberts manoeuvre. It felt like a good start.

Brainstorming cord prolapse

Explaining shoulder dystocia

Role playing shoulder dystocia...

Managing a PPH

End of the day pic...

It turns out everyone just wants someone to be kind to them...

Another morning spent at Patan hospital. There is some talk that the birthing centre, which is now a postnatal ward, may become a birthing centre again. This would be truly good news as it would be used by a high volume of women. Its not a bad space either with, easily to clean, lots of room to walk around and some degree of privacy within little cubicles. I told Rashmi if it opened up again I would come back and help her teach midwifery care to the nurses :-)

The old birth centre, currently used as a postnatal ward..
...a few mats and some birth balls and it would be grand!

Myself and Sophie then observed another delivery with aspects which were very hard to watch. Strong fundal pressure was used to help deliver the baby with a resulting cervical prolapse. Again, following delivery of syntocinon there was no delay prior to commencing CCT. It is extremely difficult to know how to feedback constructively in these situations because the nurses are so nice and welcoming and it is good of them to let us observe so freely. By coming in from the outside it almost feels slightly offensive to criticise practice and yet that is the only way any hospital anywhere in the world has improved. Of course a longer, more sustained placement at one hospital would allow for a build up of relationship and subsequently would make this easier, as is the case at APS. Now that I know the girls there, it feels much more natural to discuss the birth centre and how it could be improved in a collaborative manner. With these short term observations my conclusion is that it would be best to give feedback to Rashmi who can then dissiminate it as she wishes.

All that aside, what stayed with me from the day was the woman's response following delivery. I had been at her head whispering what I hoped were comforting things into her ear and holding her hand, having no idea whether this was something she appreciated given that we had never met. The first thing she did was turn to me and say 'thank you so much for your support'. I was a bit gobsmacked really, because if I had just been through a horrendous delivery with someone pushing down on my stomach I don't think my immediate thought would be to thank some stranger. But it made me think, as obvious as it sounds, in labour, regardless of culture, people really do just want someone to be nice to them.

We went down to visit her later and she was looking much happier and breastfeeding her baby. Her mum and sister were there bringing her food and massaging her legs. I have to say the culture of postnatal support is something the UK could learn a lot from. Here the ethos is that the woman needs to be protected and looked after with the mother in law generally looking after her for at least a month. I have seen the same practice with my friend Emma - all meals and cleaning are done by the family so that all she has to focus on is feeding her baby and recovering. As a result she does not have the overwrought, tearful and exhausted look I have seen in so many new parents. The alternative is very nice to see.

A baby boy

In the postnatal ward being looked after by her sister...