Monday, April 30, 2012

H+BAC=?

TROUBLE!
[H+BAC stands for Home + Birth After Caesarean]

I have written about births after caesarean from time to time on this and other blogs. Last August I focused briefly on 'A scarred uterus', in the context of guidelines that had been hastily put together by ACM, and which were subsequently adopted by the National Board as its regulatory position on homebirth [link].

Yes, according to this statement homebirth is contraindicated for the 'scarred uterus'. Just to put the 'scarred uterus' in perspective, the Australia-wide rate of caesarean birth is more than 30% of all births [See Australia's Mothers and Babies 2009 report, published Dec 2011]. That's a lot of scarred uteruses.

Q. When a woman who has one of those scarred uteruses wants to have another baby, and she wants to optimise her chances of vaginal birth (vbac), to whom does she turn for professional help?
A. An experienced midwife who is committed to working with each woman, protecting promoting and supporting healthy physiologically normal processes in pregnancy and childbirth.

Q. Where do you find a midwife like that?
A. A midwife in private practice is able to make a personal commitment to the individual woman, and work professionally with her as her primary carer.

Q. Where does the midwife work?
A. The midwife's work is limited to the home, because (except in a few cases) midwives in private practice are unable to be recognised as a woman's midwife once admitted to hospital.

Q. What does the woman with the scarred uterus need to do in order to plan vbac?
A. The woman who is healthy with a healthy fetus at Term, who experiences spontaneous onset of labour, and who progresses in labour under the natural hormonal environment without medical assistance (augmentation or analgesia), is most likely to give birth spontaneously without complication.

Q. So, coming into spontaneous labour - that happens best at home?
A. Correct.

Q. And progressing without medical assistance - that happens best at home?
A. Correct.

Q. And that's where the midwife is experienced and competent?
 A. Correct.

Q. So, why is homebirth contraindicated?

[But there's a hole in the bucket, dear Eliza ...]

Of course this little Q&A sequence is overly simplistic.

But the point I am trying to make is that 'home' is not the key issue.  The central issue is that a midwife is the most appropriate and expert primary professional care provider for any woman who intends to give birth under normal physiological conditions, using natural oxytocin, natural adrenalin and catecolamines, natural endorphins, natural anti-diuretic hormone, and all the other amazing substances that work together in the healthy body to bring a woman to safely and proudly give birth to her baby.  The woman who is able to proceed in labour with the confidence that her midwife is protecting the birthing space, and that her midwife will identify and act appropriately to protect the wellbeing of both mother and child if needed, is able to look forward to BAC, whether they are at home or in a supportive hospital environment.

Achieving vaginal BAC is core business of midwifery.  It's where the midwife's skill is most needed, and where an experienced midwife is confident and in her element.

Yet, BAC is 'contraindicated' in the one place where the woman is most able to proceed well, and the one place where the midwife is able to work without restrictions.

Midwives who are facing up to this dilemma that has come about as a result of hasty bureaucratic processes that failed to consult with the midwives or the women it affects most, do not have many choices.  Either we continue to attend women with scarred uteruses professionally, or we refuse to do so.  The latter alternative is likely to result in some women facing unnecessary repeat caesarean surgery, with the inherent compounding risks of abnormal placental implantation and severe haemorrhage; and some will take the other extreme pathway - freebirth.

The central issue is not about the big 'H' - homebirth.  The central issue is the midwife's right to engage in professional practice.  A midwife who is attending a woman in labour, with or without a scarred uterus or any other of the listed contraindications, or complication, is professionally able to work with the woman to make appropriate decisions.  In some cases that may mean going to hospital; in others it means staying at home.  At all times the wellbeing and safety of mother and baby guide the midwife's professional advice.  Home is only a setting.  Healthy mothers and babies are the outcome we desire.


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