VBAC statement from RANZCOG

A new College Statement on Planned Vaginal Birth after Caesarean Section (Trial of Labour) has been issued (July 2010) by the College of O's and G's, RANZCOG. 

Midwives who are monitoring the current state of maternity reform in Australia are aware of increasing pressure on both women and midwives to comply with RANZCOG's professional guidelines.

In this statement RANZCOG has summarised its statement of risks to mother and baby, of both 'Trial of labour' and repeat elective caesarean surgery, and its recommended plans of care. 


Recently I was with a woman who was planning vbac at home in my care, as an obstetrician was reviewing my client whose pregnancy had progressed to 11 days past 40 weeks.  The doctor listened with empathy as the young woman explained that she felt severely traumatised by the caesarean birth after induction of labour for her first baby.  The doctor considered that a trial of labour was a good plan, but was adamant in objecting to the plan for home birth. 

The doctor's explanation of risk was:
"One in 200 women who attempt vbac will experience uterine rupture.
"One in 10 of those who have uterine rupture will experience serious consequences - either serious (maternal) haemorrhage or still birth."

These risk figures are consistent with the references quoted in the College Statement on Planned VBAC.  Multiply 200X10, and according to this doctor there is a risk of 1 in 2000 that an attempted vbac will have an adverse outcome.


The doctor did not mention to my client that elective repeat caesarean increases the risk to her, particularly in her chance of serious haemorrhage, leading to hysterectomy, and even death.  Her risk of abnormal placenta implantation (previa and accreta) was increased in subsequent pregnancies.


Pregnant women are often faced with many risk calculations.  In early pregnancy when they have screening for Down Syndrome they are greeted with risk ratios that would be more familiar to bookmakers than to most mothers-to-be.   Many feel bullied by the use of statistical reckonings that seem to have been pulled out of thin air.

Here are a few other statistics to consider:

Despite impressive advances in technology and treatments Australian parents experience the tragedy of loss of a baby in approximately 10 in 1000, or 1 in 100 births (perinatal mortality rate in 2006, from the National Perinatal Statistics Unit).

The rate of babies born with Apgar scores less than 7 at 5 minutes in 1.5 in 100 births or 15 in 1000 births (PDCU 2007) in Victoria.

Women giving birth in hospitals have approximately a 30%, or 30 in 100 chance of caesarean birth.  Women having their FIRST baby in certain private hospitals have a 50%, or 50 in 100 chance of caesarean birth. 

Comparing these risks with the 1 in 2000 risk of adverse outcomes for vbac makes vbac sound relatively safe.

Midwives advising women who are intending to give birth physiologically will encourage minimal interference as labour establishes and progresses.  If their plan is to go to hospital for the birth, the transfer will usually occur after the labour has established.  Key features of midwife care for planned vbac include:
.trust: the woman and midwife establish a partnership based on reciprocity and trust
.the woman calls the midwife to be with her at her home when her labour has established
.the midwife carries out basic assessments of fetal and maternal wellbeing, and progress, in an unobtrusive way
.the woman is able to proceed to home birth vbac, or to make an informed decision to go to hospital when and if needed

The RANZCOG College Statement sets out advice on TOL (trial of labour), including:
.admission to hospital relatively early in labour
.intensive maternal and fetal surveillance intrapartum, including continuous electronic fetal monitoring.

Clearly there is a huge difference in the way independent midwives and obstetricians approach vbac.   There is no evidence of poor or worse outcomes when women plan vbac at home.  Some go to hospital; some proceed to vaginal births in hospital and some proceed to another caesarean birth.

Reviewing July 2010

In a world that is constantly changing, one thing stays the same: babies are conceived and grown, in the bodies of their mothers, and the time comes for every one when she or he must be born.   The physiological, natural process is the standard way, just as breathing is usually done without drugs or machines.

In the past few weeks Australia has seen its first female Prime Minister, Julia Gillard, take over the reins of government, and a federal election has been scheduled in August.

The polls tell us that women are preferring Ms Gillard. Is she worthy of our trust?

Julia Gillard was the Opposition health spokesperson in the leadup to the last federal election. She was instrumental in assuring women that maternity reform was a high priority for the Labor Party.

The Australian people elected the Rudd Labor government, and Julia Gillard became the Deputy PM. The Health portfolio was passed to Nicola Roxon; the Maternity Services Review and various offshoot inquiries were held; and the government meekly followed the directions laid down by the medical lobby.

That's all on the record.

Birth IS important to women, and to their midwives.
Birth IS NOT an illness - to be managed, treated, and cured.

Decisions made by any woman going through any natural physiological process, such as pregnancy and birth ARE of profound significance to that person and her family. The mother not only (literally) takes the baby home; she takes her body and mind home. Many new mothers do not make the adjustments well; many suffer depression and post traumatic stress for years after what should have been a satisfying time of personal growth and development.


A group of mothers and midwives in Brisbane, under the Maternity Coalition banner, rallied yesterday as the PM and the Health Minister announced funding for mental health initiatives.

“We welcome Julia Gillard’s announcement about increased funding for mental health. Suicide is the leading non-direct cause of death for new mothers. We know that good quality maternity care, including from a known midwife, is likely to be protective against post-natal depression”, said Melissa Fox, West End mother of two and Vice President of consumer group Maternity Coalition’s Queensland Branch.

We know that rates of depression can be reduced when women receive primary care, with appropriate social support, from a known and trusted midwife. As it happens, primary maternity care from a midwife is THE very issue that the Australian health care system refuses to support.

Why?

Simply because the medical profession considers it in the public interest that all maternity care be carried out under medical supervision and strict medical protocols.

Ms Fox noted “The Government has committed $120m to Medicare for midwives. We call on the Government to remove the legislative barrier to enable the reforms to work. No action on the part of the Government would result in no improved access for women to midwifery models care ”.


In a similar press release, birth activist Justine Caines claims that:

"Women’s Rights Removed under Female PM - Sometimes it does Matter that the PM is a Woman.
The new Gillard Government has removed the basic rights of women in childbirth, with legislation that requires medical permission for all elements of [maternity] care.

"These moves mean that a doctor not a woman will decide. Most women seeking private midwifery care have gone out of their way to seek this option" Ms Caines added

"The Gillard government has just annihilated those choices, giving doctor the say over women's bodies and births."

“Minister Roxon’s total mismanagement of the Medicare for Midwives initiative will have far reaching consequences across the health sector. Childbirth accounts for the greatest number of hospital bed stays and yet we have a Health Minister putting doctors hip pockets over whole of maternity reform.”

Links:
Maternity Coalition Queensland blog
Maternity Coalition website
Homebirth Australia

post script:
The world of private midwifery practice for women planning homebirth is not very different today than it was prior to the last election. The substantive difference is that midwives now must:

• have indemnity insurance to cover all pre- and postnatal work, with homebirth being exempt
• obtain consent from women that they wish to proceed in the care of an uninsured midwife if they give birth at home.

The current status of access to homebirth midwives will have changed in some communities, particularly in rural areas.  A number of midwives who had previously attended a small number of homebirths each year have withdrawn from homebirth practice.   Many midwives are confused about the indemnity insurance rules and products.  The information and links at the MiPP blog is up to date.  A disproportionate number of midwives in private practice are currently under investigation by the regulatory authority, and one Victorian MiPP has had her licence to practice suspended.
Some MiPPs are preparing to be eligible for Medicare, hospital visiting access, and other extensions to practice (prescribing and ordering tests), which is scheduled to be in effect in November this year.  There are many unanswered questions in this arena - pregnant women whose babies are due in November and subsequently should not hold your breath for Medicare rebates for your midwife's fees, or for your chosen midwife to attend you privately in a public maternity hospital.