The new Statement on Planned Vaginal Birth after Caesarean Section (Trial of Labour) C-Obs 38, issued July 2010 by the College of Obstetricians and Gynaecologists, RANZCOG, requires critical review.
Yesterday I commented in another blog on the 'risk' picture presented in this Statement.
The ultimate statistic:
RANZCOG notes an "extremely low but clinically important frequency of adverse outcomes", notably maternal death, for women who have elective repeat caesarean surgery (ERCS). However, RANZCOG deftly attributes the reason for the "apparent association" to "women with complex medical and obstetric problems [who] are much more likely to feature in the ERCS". This statement is dishonest and misleading. Women with no medical or obstetric problems have added to maternal mortality and serious morbidity statistics after caesarean surgery that has been undertaken for non-medical reasons, or after a cascade of interventions that began with medical interference in an otherwise uncomplicated pregnancy.
Homebirth for VBAC
While the 'H' word is not prominent in the RANZCOG statement on VBAC, it is understood from a previous College Statement (C-Obs 2) that RANZCOG "does not endorse home birth". This position has been clear since 1987, and has effectively prevented any useful dialogue on home birth between midwives and most obstetricians. It's a matter of joining the dots.
Having declared its standard for antenatal preparation; intrapartum care; contraindications to Trial of Labour (TOL), and TOL in risk-prone circumstances, the RANZCOG statement on VBAC has defined the option of "TOL" in "risk-prone circumstances" as "sub-standard care" [emphasis added].
"A TOL may become particularly risk-prone where: there is a lack of services for safe provision of emergency care (eg a TOL conducted at home, birth centre or centre without ready access to obstetric, anaesthetic and paediatric support); there is a failure to provide or accept adequate intrapartum maternal and fetal surveillance; and there are clinical circumstances such as outlined above (eg more than one previous caesarean section)"
It is pretty clear to me that RANZCOG's TOL is unlikely to proceed to a spontaneous vaginal birth, with a healthy mother and baby. This statement exposes the lack of recognition of childbirth as a physiological process that is normal and good; a process that is in delicate hormonal balance. Throughout the document the reader is reminded repeatedly of the risk of rupture. It comes up like an advertisement: "remember you might need an obstetrician".
How often is the risk of rupture likely to result in catastrophic outcomes?
About 1 in 2000 labours for planned vbac.
There are many factors to be considered by women who have had one or more previous caesarean births. The Births after Caesarean INFOSHEET, available at the Maternity Coalition website, summarises the choices that these women may face.
Midwives who agree to provide primary care for women planning VBAC, whether the birth is planned for home or hospital, face potential criticism based on the RANZCOG Statement. The Statement advises that before a midwife agrees to "administer care in risk-prone circumstances, that the women agree to counselling by a senior obstetrician who should ... [read on, there's a real sting in the tail of this one! That selfish woman needs to know that she is potentially imposing "considerable demands on the limited resources of the health team, with potential adverse consequences not just for her and her baby, but also for other women and their babies"]
Feeling guilty now?
Why don't you just roll over?
In this RANZCOG Statement on Planned Vaginal Birth after Caesarean Section I have found material for all the bullying and manipulation that is needed to force women into submission to the medical system. While acknowledging a woman's right to make choices, the Statement sets the stage to shackle those who have the ability and skill to recognise and address complications early if they occur, while working in harmony with the natural physiological processes that lead to safe and joyous birthing. Under this Statement the rate of Caesarean births, and all the related complications, is likely to continue to rise in Australia and New Zealand.