Thursday, January 20, 2011

Risk aversion

Midwives who attend women for homebirths have often been portrayed as having an affinity or fondness for risk, accepting and even encouraging situations that would not be considered suitable for midwife-led care in hospital.


A new blog Labor Intensive at Medscape asks big life and death questions with relation to risk aversion and the increasing rates of Caesarean births in the USA. The same questions apply in Australia, and in many other places. The blogger, Chavi Karkowsky, MD, Ob/Gyn, Women's Health, writes:
When consenting a patient for a primary cesearean section for breech - a scheduled, routine, low-risk occurrence - do you include the risks of:

a) Cesearean hysterectomy?

b) Damage to fetus/infant?

c) Maternal death?

I used to mention both (a) and (b), routinely. Risk of bleeding, infection, damage to organs, and small risk of cesarean hysterectomy; remote risk of damage to the fetus. Well, these things happen, they do, right? We've all been there, or at least known someone who has been there for the completely unexpected c-hyst in the young primip, or the wildly unimaginable scalpel laceration or broken femur during delivery of the infant.

But is it really reasonable to bring the spectre of the tremendously unlikely to bear? Is it fair, especially when what you're offering is standard of care, and there is no really clinically reasonable other way out? Is it even, really, truthful?

Good questions. A blog worth watching.

I would enjoy dissecting the statement "and there is no really clinically reasonable other way out" - but that would divert me from my theme, and I suspect that when I write long blogs they don't get read.

In the world of private midwifery in Melbourne today, I sometimes 'discover' a baby who is presenting breech at 35 or more weeks' gestation. The discussion that follows includes:
  • understanding breech presentation
  • confirming the baby's position and presentation
  • options for turning the baby, including referral for external cephalic version
  • discussion of breech vaginal birth


Mothers with breech babies have huge decisions to make. A midwife who encourages informed decision making is leaving open the possibility that the woman may choose to proceed, against medical advice, with vaginal birth.    The very act of the midwife in encouraging the woman to make her own decision, rather than accepting what is presented as the "standard of care, and there is no really clinically reasonable other way out" (the risk-averse position) can be seen as risk affinity.


A somewhat different blog that also came across my screen today is entitled Competitive childbirth - it’s ‘mum-upmanship’, in THE PUNCH, by Emma Grey.
Nicole Kidman has welcomed a new biological daughter via a ‘gestational carrier’, Princess Mary had her twins in a natural, four-hour birth and Miranda Kerr released a statement that she gave birth to her 9 lbs., 12 oz., baby in a long, arduous and difficult labour ‘naturally, without drugs or painkillers!!!’.

I took the opportunity to comment, affirming the safety of the normal physiological for mother and baby in most cases, and asked "why would anyone intentionally take the medicalised route, when such a free and functional, even pleasurable, route is the physiological norm?"
This question drew a sarcastic response "Who are you to judge? Just shut up and give me the drugs.", and another "I wonder if you have experienced childbirth yourself, because believe me, the reality can never be properly prepared for, no matter how well- informed we are beforehand. Once we are in the moment, we cope as best we can, even if that means yelling “Where’s the bloody pethidine?”



While the risk-averse medical/obstetric profession struggles with the ethics of confronting a woman with certain information, there are strongly held community beliefs that medical management of birth is the only acceptable way to proceed. When a midwife who understands risk and bodily autonomy in birth differently from her medical colleagues facilitates a choice that is not understood by the general public, or professional colleagues, and supports a woman through difficult decisions, that midwife may, in fact, be fulfilling her duty of care to promote and protect normal birth in partnership with the woman.


For more on breech births, go to my Private Midwifery blog.

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