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.

Reflection on practice

Today I am using Gibbs' reflective process in reviewing an experience I have had recently, attending a woman, who I will call Linda (not her real name), giving birth in hospital. I do not want to approach this from an idealistic standpoint, or to 'deamonise' the hospital. Birth, as with the rest of life, is full of unpredictable moments when those who are present are called upon to do their best.

Alena welcomes her baby brother, Christopher

I want to assure readers that mother and baby are well.  However, I am left with some difficult questions. I question my own actions as well as those of colleagues in the hospital.

1. What happened?
Linda was treated unnecessarily (imho) and aggressively for obstetric haemorrhage.

2. Feelings: What was I thinking and feeling?
I was shocked, surprised, and bewildered when I realised that there was a full-scale emergency 'code' being performed, with not only active management of the Third Stage, but additional oxytocic drugs intramuscular Syntometrine, intravenous Syntocinon (40 IU in 1 litre of fluid) administered urgently.

3. Evaluation: What was good and bad about the experience?
What was good? Having experienced respectful care from the doctors and midwives through the pregnancy, and engaged in carefully informed decision-making up to the moment of birth, this incident was an over-reaction to Linda's known risk factors (including multiparity, and a previous caesarean birth)
What was bad: I realised that I had facilitated this chain of events, because I encouraged Linda to agree in early labour to having the IV cannula sited in her arm.

4. Analysis: What sense can I make of the situation?
I can understand why this incident happened, because I know about other very difficult incidents that this group of midwives were dealing with.

5. Conclusion: What else could I have done?
At present a midwife practising privately is not able to have visiting access for clinical privileges in hospitals in Victoria. I cannot over-ride the clinical decision of another midwife, and when an emergency code has been called, I would be foolish to interfere. My long term hope is that I will be able to have clinical practice rights in public hospitals, and in this case I would be able to take responsibility for my own clients.

6. Action Plan: If it arose again, what will I do? 

As I noted in #3 above, I had encouraged Linda to agree to the hospital's policy and have an IV cannula sited in preparation for an incident such as a post partum haemorrhage (pph). I believe Linda would have declined the offer if I had not spoken to her about it. In this case I think it was the fact that the cannula was in situ, and the hospital midwife was basically 'set up' for a pph, that somehow set the pathway.

In another similar situation, I will be careful to inform the mother that once a cannula has been sited, it is easier for staff who may be on edge for totally unrelated reasons, to 'jump the gun' and treat her as though she is in an emergency, when this is not the case.

Reflecting on progress in midwifery

Hello Grandpa!

When I studied midwifery (in the early 1970s) we learnt about the hormones in the menstrual cycle and the physiology of conception. We learnt about FSH and LH and oestrogen and progesterone and testosterone. We knew that oxytocin existed, but it was just the hormone the caused contractions of the uterus. The synthetic copy of oxytocin, Syntocinon, was used liberally as it could be measured and given in a 'scientific' way. I don't know if oxytocin crucial role in milk let down and love making was mentioned. The action of endorphins as natural opiates, and adrenaline and nor-adrenaline were part of that complex mystery waiting to be better understood. I don't remember any mention of bonding or maternal behavioural adjustments.

When Noel (my husband for the past 37 years) studied veterinary medicine in the late 1960s he learnt the same physiology. Vets became fascinated with the world of artificially managed conception, ovum transfer, and surrogacy in the world of producing the fittest and most highly desired offspring.

Noel's Masters and PhD research explored the protective effect of colostrum in the newborn calf. He showed that colostrum protects the calf against diarrhoea (scours) and septicaemia (blood poisoning) in the early days after birth. This result sounded obvious to me, but was important scientific knowledge at the time. My journying with him through academic processes, including the literature review and carrying out the research, informed me a great deal and opened my mind to critical thinking.

... move through time to today.

Noel and I are now doting grandparents. We have seen huge changes in our own understanding of the physiology of all things to do with childbearing, reproduction, and a human mother's ability to love and care for her child.

Acquiring knowledge of natural physiological processes in childbearing and nurture of the infant has been a fascinating journey that has, for me, absorbed my mind over most of the past three or four decades. It's an incomplete process.

As long as I am able to call myself a midwife I will have a duty of care to promote normal birth. I hope that midwives around the world will also claim that purpose.