Helen Shallow looks at women, VBAC, choice and decision-making
In 2013 I wrote about 'deviant mothers and midwives'1 when I described my journey to support women having vaginal birth after caesarean section (VBAC). That journey started soon after I qualified as a midwife in 1987 when I encountered women giving birth unexpectedly after being told they could not possibly give birth vaginally as their pelvises were 'too small'. very early in my career back in the 1980s I started to question the prevailing rhetoric that 'once a section always a section' when I met women who, despite being told their previous caesarean was due to a narrow pelvis, would arrive and give birth before we had a chance to rush them to theatre.
However, we have come a long way, and I would like to share two accounts of women whose first babies were born by caesarean section who then chose not to give birth in an obstetric unit despite the hospital recommendations and NICE guidance that they should. I have been supporting such women for much of my career and latterly more formally in my role as consultant midwife and then as a head of midwifery as well. My deep-rooted belief is that women have the right to selfdetermination and autonomous decision-making. As simple and obvious as that may sound, nowhere is this more problematic than in maternity care in most highincome countries where birth interventions are on the rise and normal birth is in decline.
Rules, guidelines, checklists and protocols all but stifle individual decision-making and generally do not engender partnership working between women and midwives. The legacy of 20th century dogma around childbirth has led midwives to fear stepping out of line to support women when they request to use the pool, to have intermittent auscultation or to give birth in the birth centre or at home when hospital guidelines recommend otherwise. The phrase I have often heard from reluctant midwives is 'I'm protecting my registration'. Registration with the Nursing and midwifery Council (NMC) ensures midwives are legally entitled to practise midwifery.
In a similar way a woman's agency or sense of self is undermined when she is met with opposition, cynicism and sometimes hostility when she refuses to comply with rigid rules around how she should birth her baby. However, the climate is slowly changing and improving, and notably as the discussion about women, childbirth and human rights has come to the fore2 many NHS midwives and doctors are picking up the mantle and making change happen towards a new dialogue of partnership working and women centred care. Nevertheless, we still have much work to do. The following are just two examples of women successfully having VBACs from my personal experience. I have changed names to protect anonymity.
The National Institute for Health and Care Excellence attempts to bring together evidence related to any given medical condition or in this case pregnancy and birth and formulates recommendations based on the interpretation of that evidence. www.nice.org.uk
Sally had a caesarean section with her first baby after prolonged rupture of membranes and failed induction. On reflection Sally believed that had she waited longer, her labour would have started by itself and the caesarean might not have been necessary. However, she was persuaded by the standard recommendation that, after 24 hours of ruptured membranes, if a woman's labour has not started, the hormone drip (syntocinon) is commenced to push the labour on. Sally did not feel she had a choice in the decision and as soon as 'risk to baby' was mentioned she knew she would follow professional advice. This time, however, she felt stronger and more sure of herself. She simply wanted the opportunity to birth her baby without interventions. She determined that the birth centre was the best place for this to happen.
In 2008 the freestanding birth centre in West Yorkshire had not been open long and I led on setting it up and wrote the guidelines and criteria for the birth centre based on NICE guidance. No other recommendations at the time would have been acceptable. I anticipated that women who did not 'fit the criteria' would also want to use the birth centre, based on prior experience in another maternity unit. I therefore compiled a 'framework' to support women who make decisions outwith Trust recommendations. I involved the obstetricians and senior midwives from the outset so that we all agreed a mechanism to support this group of women. For midwives this resulted in open and honest communications without feeling threatened or guilty that in some way they were breaking the rules. Midwives found the framework particularly helpful and obstetricians accepted that some women would choose midwifery-led care despite their advice to the contrary.
This included some women with a high BMI or women on medication for other conditions who would have been advised to have an obstetric unit birth.
Sally's waters broke again 'just like last time' and we, no I, had an anxious time crossing fingers and toes that her labour would start spontaneously. We kept in touch and I am convinced the relationship and rapport that we had built up over the months helped her to relax and let go so that her labour commenced spontaneously. She birthed in the pool in the birth centre and was delighted and triumphant as so many women are when they experience their own power, sometimes for the first time. Milly's story – not quite a birth centre birth, but triumphant nevertheless
Milly had a previous caesarean section due to genuine concerns about her baby in early labour. The caesarean section was the right course of action and Milly was happy her baby could be supported appropriately soon after the birth. Two years on and pregnant again, she expressed the desire to go to the birth centre. She was not considered a suitable candidate for the birth centre due to her previous caesarean section but she challenged that decision and was sent to my clinic for further discussion. I think some midwives and some doctors mistakenly believed I would talk women out of their decisions!
That was not the purpose of my clinic. Nor was the purpose of the meetings just to say yes that's fine off you go. I felt the purpose of our meetings was to get to know Milly and other women like her. I wanted to explore what was behind their requests to do something that the Trust did not recommend. Consistently I found that women simply wanted a chance to give birth with support and minimal interference or intervention, be that at home or in the birth centre. They wanted the opportunity to labour in an environment that best suited their needs, calm and relaxed and not rushed and noisy. Milly was very clear about her motives and that safety for her equated to the birth centre and not the obstetric unit. She did not want to be treated as 'high risk'. She wanted to be treated like any other mother having a baby.
We talked about the travel time should transfer be necessary and we discussed how midwives would know if problems were developing in labour. Just as in a home birth Milly understood that transfer meant a potential delay if any emergency treatment was required. Milly was fully informed about what the birth centre could offer and what it could not. In support of her decision to use the birth centre I gave her a copy of the VBAC framework to keep with her notes and I wrote to the birth centre manager, and copied this to the consultant, with her details so that the team would know to expect her.
Milly went into labour around her due date. The photograph shows her working hard in the birth centre as she worked through her labour. However, at a key point the midwives became concerned that her labour was not progressing and she was still having strong contractions. After discussion with Milly, she agreed to transfer to the obstetric unit. About two hours after the transfer Milly gave birth to her baby. Like Sally she was ecstatic. She wrote to me afterwards and described how well everyone had supported her and how her care had been seamless throughout. She felt the midwives at the birth centre had done their best to support her. She had used the pool and tried all the active birth techniques to progress her labour. She agreed the need to transfer and found the labour ward team welcoming and supportive, and she felt that they helped her to achieve the normal birth she had so longed for. Milly was triumphant and delighted. She agreed that I could use her photograph to share her story with other mothers who might be in a similar situation.
I chose to share Milly's story because we need to move away from blunt choices. Choosing one option such as birth at home or birth centre birth does not exclude the help and support that may be needed if and when that need arises. Surely that is a better approach? In other words as the government documents repeatedly suggest: appropriate care in the appropriate place at the appropriate time.3,4
In conclusion the way forward for women who don't fit standard criteria for out-of-hospital birth, be that in a birth centre or a home birth, is to seek out midwives who will engage with them and work in partnership with them to ensure that they have all the information in a non-biased way so that it is their decision. No-one can force a woman to do anything without her permission, but unfortunately the 20th century legacy of fear around childbirth still casts it shadow and we have more work to do to support women to realise their potential. However, when women know their rights and know what is possible and midwives are supported to facilitate women's decisions, the power of women is unleashed and the most extraordinary ordinary normal births result.
Helen Shallow is a freelance Consultant Midwife.
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