Leeds Trust fails to follow National VBAC Guidelines

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AIMS Journal, 2020, Vol 32, No 1

By Helen Cox

Leeds Trust are denying women who are planning a vaginal birth after a previous caesarean (VBAC) the best chance of a successful vaginal birth.

RCOG¹ recommends that women who have previously had a caesarean are offered an appointment with an obstetrician in order to discuss their plans for birth. This is an opportunity for health care providers, and women who have had a previous caesarean, to talk about their options for birthing their baby. In some areas of the country these clinics are midwife-led, with a linked obstetrician should the need for additional support arise.

Women accessing care via the Leeds NHS Teaching Hospitals are increasingly reporting being coerced into aligning their plans for birth with the preferences of the obstetrician counselling them, in what is, in Leeds, an Obstetrician-led clinic. Women have reported being told of babies dying because of the birth choices made by their mothers, horrific and shockingly detailed descriptions of the mechanisms through which their babies might die (including ways which are not related to VBAC), partners in the appointments are being asked if they are happy with the decisions their partners are making – with an indication of the doctor feeling that the women’s decisions are not safe. Many women are reporting that they are being told that they are not allowed to birth in the place or in the way they wish to, and they are being told that they may not use a birth pool as pain relief and comfort in labour.

Quite aside from the obvious confidentiality breech when women are told of specific cases, this is unacceptable. The need to offer women information about the perceived safety of different birth places and choices does not give carte blanche for health care providers to frighten women into submission, which is what women are reporting. To withhold the availability of a form of analgesia, labouring and birthing in water, is unethical and does not align with research evidence or the most recent NICE guidelines relating to VBAC ((NICE) 2019), which state, “Support informed choice of a full range of options for pain relief for women who have had a previous caesarean section, including labour and birth in water.”

It is necessary to offer women information about the relative outcomes for vaginal birth vs. caesarean birth due to the possibility of uterine rupture, which is increased in women planning a vaginal birth after previous caesarean compared to women who haven’t had a caesarean. The RCOG state that:

“Women should be informed that the absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous women” ((RCOG) 2015)

This does not align with an approach of telling women of cases when babies died, or describing the minutiae of how babies may die. This moves from a conversation aiming to enable women to make an informed decision to coercion, and breaches the codes of conduct that both doctors and midwives must adhere to.

Leeds NHS Trust, unlike other trusts of its size and many much smaller, has never had a consultant midwife. Now that we’ve lost the services of the Supervisors of Midwives, and in the absence of a consultant midwife, women report struggling to access support after antenatal appointments in which their plans have been blocked. Some are referred to a Birth Matters clinic, the remit of which involves birth debriefing and planning, but with waiting lists of weeks or months and the requirement to re-book in to see an obstetrician in order to attempt to negotiate access to birth pools or non-obstetric settings, this pathway is not functioning effectively.

The new ‘alongside midwife led unit’, the Lotus Suite, at Leeds General Infirmary, is a less clinical-looking area than the main obstetric ward, which has been achieved by installing a set of doors which block off the bottom three labour ward rooms, and redecorating them. Six months ago, these were labour ward rooms, and women having a VBAC were among those using them. A set of double doors and a coat of paint later, women are now being told that it is unsafe for them to birth in this area of the labour ward, despite the fact that we know how important a calm and relaxing environment can be to a successful and positive physiological birth. They report being told that they must birth in the more clinical looking obstetric rooms just up the corridor, with access to the Lotus Suite rooms blocked by the requirement to speak to and negotiate with the right consultant.

Why is it that in one of the UK’s largest teaching hospitals, supporting around 10,000 births per year, women are subjected to this pressure to conform to care that doesn’t reflect the best available research evidence or the NICE guidelines? How can a hospital which should be leading the way in VBAC care be going backwards in its support for women? And most importantly, what are the Leeds CCG (Clinical Commissioning Group) and Trust management going to do to change this situation?

References:

1. (RCOG), R. C. o. O. a. G. (2015) Green-top Guideline No. 45 : Birth after previous caesarean birth. London: RCOG. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_45.pdf

Helen Cox is a pseudonym.