Tuesday, August 25, 2009

"Why bother coming here if you won't let us manage you the way we think is best?"

Why indeed!

This is the question that a mother was asked by a doctor. Not a junior, down the line doctor, in a small under-resourced hospital. It was the senior obstetrician in one of Melbourne's three tertiary, state-of-the art, well resourced referral hospitals.

I am writing about this case because I am witnessing a more intense effort by hospital staff at coercion and bullying to make this woman comply than I had anticipated or experienced in the past.

The mother's problem is that she is carrying twins, AND 'Twin A' is presenting breech, AND she wants to give birth spontaneously, rather than agree to elective caesarean surgery.

In good faith the mother accepted my advice to attend the hospital for review after her twin pregnancy had been confirmed.

The hospital's reason for insisting on surgery: they can't be sure there will be a doctor who is competent for a vaginal breech birth, let alone twin breech, when the time for birth comes. Even in a tertiary level hospital, funded to provide competent staff round the clock to provide appropriate obstetric and midwifery services for any woman, the pressure is on to manage a slightly complex case in the day shift.

The midwifery profession has clear guidelines for consultation and referral, and I find these guidelines reasonable. In a situation such as this one, when a woman planning homebirth in my care is found to have twins, I encourage her to obtain information from the back-up hospital, and make an informed decision about her birthing. I do not push vaginal birth at any cost. The safety and wellbeing of mother and child(ren) is my primary concern.

Although I have no visiting access in hospitals, I don't need that to practise my skill as a midwife. All I need is the partnership of trust with the woman. As long as she is confident to proceed in harmony with her body through the birthing process, I can reassure her, and guide her professionally if decisons need to be made.

I have not shut the door to homebirth with twins. It is not my door to shut. The woman needs to make her choice, and I am committed to being with her as her midwife in the setting she chooses.

I know this woman has a good chance of giving birth safely and spontaneously to her two babies. I know this from my knowledge of the woman, and her previous births, and her wisdom and deep faith in God, the giver of life.

I also know the decision points that may be reached in vaginal birthing of twins.

The question, "Why bother coming here if you won't let us manage you the way we think is best?" offers a clue as to the real problem. The mother does not want to be 'managed' in the first instance by anyone - doctor or midwife. She wants to proceed in her birthing under her own natural process. If the baby or babies became distressed, or if her labour failed to progress, the hospital is able to offer specific remedial action - surgery. But that's a decision point that has not yet been reached yet.

I fully support the woman in her desire to hold off that decision until, if, and when it needs to be made.


Rachael said...

I just don't understand the all or nothing mentality out there...

Surely an OB is intelligent enough to understand and his coercion is for no benefit but his own?

I have had two planned homebirths, one that resulted in a tfr for PPH. Is it not fair that I can go to the hospital when and if I need it?

I have tried to explain to those who want to birth in hospital that that is fine...make that choice, but do it knowing that there are protocols and they are based around what is convenient for the hospital, not necessarily what is convenient or best for the birthing woman.

Joy Johnston said...

Stitch Sista, your comments are so very helpful. The all or nothing mentality is truly incomprehensible. A woman who makes a choice that differs from the 'recommended' course of action needs to be respected.
It is experiences like this one that are likely to push some women into considering unattended birth as their best option. The hospitals need to wake up to that fact.