Mar 17, 2007 03:29 AM
I'm am seeking some support and advice.
I am a homebirth midwife in Australia. In the last 12 months i have been actively supporting homebirth VBAC's. I expect to have assisted around 20 women to birth at home following C/S this year. I have become the most outspoken supporter of these women in Australia and am being phoned by women through out Australia and women are moving from interstate to be able to access my care.
About 6 months ago the director of Midwifery asked to meet me and said during the meeting that if it was seen that i was out side 'safe practice ' she would ensure that i would be reported to the nurses board. Following this i have had 2 letters from the Director of Obstetrics, at our major teaching , almost quoting her after they have reviewed my clients during pregnancy ( as is required by the Australian College of Midwife. which my practice complies with).
I'm am looking for international research/information to support the practice of women choosing to birth at home following a C/S.
I would like to meet with the Director of Obstetrics and have a good case to present to her regarding the safety and efficacy of homebirthing with women wishing VBAC.
I'm looking for advice and support about how to proceed with this and any 'papers' you are aware of to support my stance.
Many thanks in advance.
Mar 17, 2007 02:47 PM
I'm afraid I have bad news, at least from the research standpoint. The sole study of out-of-hospital VBAC of which I am aware concluded that VBAC should take place in hospitals despite achieving extraordinarily high VBAC rates and extraordinarily low uterine scar rupture rates. Here is the reference and the PubMed abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed:
Lieberman E, Ernst EK, Rooks JP, et al. Results of the national study of vaginal birth after cesarean in birth centers. Obstet Gynecol 2004;104(5 Pt 1):933-42.
OBJECTIVE: Some women wish to avoid a repeat cesarean delivery and believe that a midwife-supported vaginal birth after cesarean (VBAC) in a nonhospital setting represents their best chance to do so; there is a small, persistent demand for out-of-hospital VBACs. We conducted a study to obtain the data necessary to formulate an evidence-based policy on this practice. METHODS: We prospectively collected data on pregnancy outcomes of 1,913 women intending to attempt VBACs in 41 participating birth centers between 1990 and 2000. RESULTS: A total of 1,453 of the 1,913 women presented to the birth center in labor. Twenty-four percent of them were transferred to hospitals during labor; 87% of these had vaginal births. There were 6 uterine ruptures (0.4%), 1 hysterectomy (0.1%), 15 infants with 5-minute Apgar scores less than 7 (1.0%), and 7 fetal/neonatal deaths (0.5%). Most fetal deaths (5/7) occurred in women who did not have uterine ruptures. Half of uterine ruptures and 57% of perinatal deaths involved the 10% of women with more than 1 previous cesarean delivery or who had reached a gestational age of 42 weeks. Rates of uterine rupture and fetal/neonatal death were 0.2% each in women with neither of these risks. CONCLUSION: Despite a high rate of vaginal births and few uterine ruptures among women attempting VBACs in birth centers, a cesarean-scarred uterus was associated with increases in complications that require hospital management. Therefore, birth centers should refer women who have undergone previous cesarean deliveries to hospitals for delivery. Hospitals should increase access to in-hospital care provided by midwife/obstetrician teams during VBACs. LEVEL OF EVIDENCE: III.
Personally, I think this is a Pilate-like washing of hands because, of course, hospitals in the U.S. are not giving women access to VBAC at all, let alone access to midwife-attended VBACs. The VBAC rate in the U.S. is currently less than 10%, and, according to Listening to Mothers II (http://www.childbirthconnection.org/article.asp?ClickedLink=748&ck=10396&area=27), over half the women giving birth in 2005 who wanted a VBAC were denied this option.
VBAC denial forces women to agree to major surgery in order to receive medical care, because, of course, labor is what happens at the end of pregnancy unless it is prevented. This is a clear violation of the medical and ethical right to informed refusal. It is also a violation of human rights in that the supposed reason for enforced cesarean surgery is that VBAC is too dangerous for the baby. Even if that were the case, which it is not, human rights principles hold that no one can be forced to undergo any invasive procedure, let alone major surgery, in order to benefit another person. That principle holds even if there is a 100% chance that the beneficiary will die, which is far from the case with VBAC. Even where VBAC is allowed, it amounts to what I call “Cinderella VBACs”: “You can have a VBAC IF the baby isn’t too big and IF you go into labor by your due date and IF you progress in labor at a rapid enough pace and IF . . . .“ You get the picture. I don’t know how accessible hospital VBAC is in Australia, but it looks from your post that things are pretty much the way they are here.
Jun 17, 2007 11:59 PM
On this note, I would like to know as a childbirth educator who supports homebirth and supports VBACs-- something that I really don't know and have been asked in class-- how long does it take for a rupture to result in a baby's death? As one class participant noted, " If you have a VBAC at home and rupture-- you're basically screwed, right?" I did not have the necessary information to answer the question-- instead emphasizing the tremendous obstacles women have getting a hospital VBAC and the risks of cesarean surgery. Can you answer this question?
Jun 20, 2007 06:19 PM
Unfortunately, the answer to your question is, "It depends." Should all hell break loose, and you have less than 10 minutes to get the baby out, then, yes, you are screwed. But you are almost certainly also screwed if you are already in the hospital. Hospitals, even tertiary care centers, can't operate that fast, you should excuse the pun.
Does that mean that all women should schedule repeat surgery to avoid this rare scenario? Nope. Repeat cesarean surgery carries risks that threaten the life and well-being of women and babies as well and that, moreover, escalate with accumulating cesareans.
Fortunately, in most cases, it is clear that something is going/has gone wrong, but there is time, including time to move into the hospital, provided the home is within reasonable distance, and the hospital is prepared to whisk the woman into surgery prep and then surgery when she arrives.
This brings up another problem whether the woman is choosing to birth in or out of a hospital: staff not believing the mother. I am aware of more than one case where tragedy ensued because nurses didn't take the laboring woman seriously when she said something was wrong or that she was experiencing unusual pain. This includes one specifically relevant to your couples. The woman came into the emergency room from a planned home VBAC, told staff she was having a scar rupture, was patronized ("There, there, Dear, labor hurts you know), and was admitted the labor ward where nothing was done for some hours. Her baby was alive when she arrived but not when they finally operated.
As things stand, few women wanting VBACs have access to an optimal situation. Most have no hospital option; they must choose between repeat surgery and the risks that entails in the short- and long-term or home birth, in some cases with no qualified birth attendant. Some can get a VBAC in the hospital but only under restrictions that make it almost impossible to achieve that goal, not to mention giving birth under the aegis of the same system that led to having a preventable cesarean in the first place. Again, home birth is the only viable alternative, although it has the drawback of possibly not getting a needed cesarean quickly enough. In an ideal world, women planning VBAC would have access to competent, supportive care wherever they chose to birth and to competent, supportive back-up should they choose to birth in birth centers or at home.
All Times America/New_York
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