The peaceful unassisted birth of Annabelle... Part 1: background

From the moment my head cleared after the euphoria of Charlotte's birth, I had known that I wanted a home birth for my next baby. I had planned where I wanted the pool to go, and had my heart set on S and C being there to witness their younger sibling's birth. When we got a surprise second line on a home pregnancy test, I was a little nervous but excited to start my journey all over again.

From the beginning, I knew I needed to do things slightly differently to last time. I hoped for the same back up gynae, and I know she is only comfortable going to 40 weeks, so I had to fudge my last period date. I also didn't want so many ante-natal visits with a gynae - there are very valid concerns about the safety of ultrasound scans, and I didn't want to expose my child to questionable practices that have somehow become standard in South Africa. So my first gynae visit was at 20 weeks after seeing my midwife at 16 weeks. (I did pop into our local pharmacy for blood pressure and urine tests at around 13 weeks).

I also discovered a couple of UC (unassisted childbirth) facebook groups and the more I read, the more they resonated with me. UC moms take full responsibility for their births and so tend to be very educated on both pregnancy and birth (including emergency situations and reasons where a transfer to hospital may be necessary).

There was a fascinating research study done a few months back, and preliminary conclusions show that UC can be significantly safer than hospital birth, and with a major decrease in the number of csections required - my gut feeling on this is that it is because each woman has taken on the responsibility to keep herself and her baby safe, and is more in tune with her body and baby than she would likely be if she was trusting a doctor to keep her safe. I feel like there is a lesson to be learned here, even for those who prefer prenatal care and hospital births.

My 2 dream birth scenarios were very different - one had S and C with Noel just outside the pool watching as their younger sib was born, and the second was an unassisted birth. The only issue with that was that I thought I may need my doula to get through each contraction again, and if she was there I needed to have a midwife present. Plus I have the most amazing midwife, and genuinely wanted her there for who she is, not just for her knowledge and experience. As it happened, we didn't have too much choice in the matter!

 

To midwife or not to midwife... and the truth about interventions

So the default childbirth 'attendant' in South Africa, even for a low-risk pregnancy and birth is a gynae (technically an obstetrician, since they are there in an obstetric role, but we all call them gynaes anyway). Why would we need a doctor when we are pregnant? We treat pregnancy as some kind of disease, as a medical problem to be fixed, and yet we are often healthier pregnant than at any other time in our lives, barring those with true medical conditions.

In a low-risk normal delivery, a gynae is called by the hospital midwives when you arrive to give birth, and is then periodically updated until they decide a C-section is 'required' or you are ready to begin pushing and they arrive to catch the baby. A hospital midwife is usually allocated to you while you are in labour, but will leave when her shift ends and another midwife comes on duty. Before you go into labour, you see your gynae every so often for 10 - 15 minutes at a time for a quick scan, and to get your urine and blood pressure tested.

In contrast, you see your midwife for an hour at a time before giving birth, she meets you at the hospital when you arrive (assuming you're having a hospital delivery - but at least you have the option of giving birth at home with a midwife), spends as long as necessary with you and you will only see her during your labour. By then you know her and trust her, as you have spent so much time with her, and she is able to encourage you in a way that is meaningful to YOU!

The contrast between the amount of time spent and the amount of money you pay for each boggles my mind! My entire hospital vbac birth (hospital stay, midwife, paediatrician and lab tests to check if C had jaundice) cost almost as much as the gynae bill alone of a friend who gave birth a couple of months before me.

But what if something goes wrong?

Firstly, something is a lot less likely to go wrong if you leave your body to birth naturally. No induction, no augmentation (to strengthen contractions or speed up labour), no pain medication. Yes an epidural is a wonderful invention - but its also likely to slow your labour down at best and can possibly stall it altogether, especially if you get it too early. Gynaes generally have much less experience in natural, normal birth than a midwife, and so tend to not trust the birth process quite as much. They get nervous when a birth isn't happening quite fast enough, or when fetal heartrate decelerates (totally normal during a contraction).

Unfortunately, one intervention tends to lead to another. You get induced because at 39-odd weeks you think you've been pregnant long enough (because, of course, pregnancy only lasts 40 weeks at most. If you are pregnant longer than your due date there must be something wrong with your body). The Pitocin you are given comes continuously, unlike the bursts of oxytocin that your body naturally produces, which causes extra-strong and extra-long contractions and your baby may struggle to recover in between contractions (usually a C-section will be recommended). Pitocin may cause placental abruption, uterine rupture, laceration of the cervix and hemorrage after giving birth, and also causes more painful contractions, so you ask for an epidural.

The epidural inhibits the production of a number of key labour hormones, increases the length of your labour (by up to 7.8 hours), increases your risk of a C-section by 2.5 times and increases the risk of pelvic floor problems (urinary, anal and sexual) after birth. Women who have been given an epidural are often confined to bed, instead of allowed to labour in the position most comfortable to them. Since they are lying on their back, their baby is 4 times more likely to turn posterior, decreasing the chance of a natural birth. Epidurals also cause immune suppression and decreased  heart rate, blood and oxygen flow in babies, and can be present for up to 36 hours after birth (similar results are seen after a C-section, often leading to sleepy babies and breastfeeding problems). Babies who are exposed to anaesthesia may also be less alert and active for up to a month after birth.

All of this is much more likely if you are giving birth with a gynae.

Midwives have seen natural births so often - they know that you can do it! And because they know what a normal birth is supposed to look like, they also know what its not supposed to look like, and will be able to identify a (true) problem quicker and more accurately than a gynae. Gynaes spend much more time practicing their operating techniques than observing natural births, and are so adept at 'picking up problems' that they often anticipate them before they even occur, leading to the interventions that so often cause more problems than they solve.

And if something does go wrong, your midwife would call your back-up doctor (or the on-call doctor if its in the middle of the night). Just like the hospital midwives would call your gynae if something goes wrong during your gynae-assisted birth. My back-up doctor knew when I was in labour, and phoned my midwife every so often just to check on how things were going - if I had a problem, she would have been there just as fast as if I had been her own patient.

I understand that in higher-risk pregnancies, more specialised medical observation is required, but a normal run-of-the-mill pregnancy is best handled by the people who specialise in normal, natural births - a midwife! She's cheaper, spends more time with you and is more experienced - its a win-win situation all around!

Between then and now

Just a quick catch-up...

The good news - the hospital allowed me to have a doula attend my birth, providing she attend an orientation meeting there, which she was quite happy to.

The bad news - when I eventually spoke to my gynae about wanting a midwife at my birth, she instantly said no. She said that a midwife's only goal was a natural birth, whereas her aim was a healthy mom and a healthy baby, and suggested that if I chose to use a midwife I would end up with a brain-damaged baby. At best, she was prepared to allow my midwife to be a doula for me, but not to take charge of the birth. The more we 'discussed' it, the more I realised that she was actually quite nervous of natural births in general, not just vbacs - and that she saw me as a high-risk patient simply because of my scar.

I may be scarred, but I'm not broken.

And we all aim for a healthy mom and a healthy baby, we just all have different opinions on how to achieve that aim.

I phoned my midwife in tears the following day, and she suggested a couple of other doctors that may be prepared to be a back-up. Every one of them ultimately said no. One even phoned me, and told me he thought I was being silly.

I began to think that she wouldn't be able to attend my birth, and stopped worrying about it - more because I didn't know how to solve it than because I had accepted it. It was only later that I realised I had to do something, when my gynae said that she was going on leave from the day before my due date. To make matters worse, her covering doctor is notoriously pro-surgery, and I think even if I arrived at the hospital ready to push, he would have carted me off to theatre to cut my baby out of me.

I then made an appointment with a local GP, who I had heard was very pro-natural birth, and she suggested another gynae I could try. Alternatively, she suggested I look a bit further to a hospital in the next-closest city and find a doctor there who would allow me to use a midwife in that hospital.

I emailed her suggested gynae, and after almost 2 weeks of waiting (just as I was ready to start making phone calls to enquire about supportive doctors in the other city), she replied that she was quite happy to be my back-up providing I come in for a consultation to discuss concerns prior to my vbac attempt. I was 34 weeks pregnant and I finally had a back-up doctor!

She was very thorough, and had phoned around to check on how responsible my midwife was before agreeing to be back-up for her. She also did a scan, and checked fluid level, as well as baby position (occiput posterior that day - but thankfully she moved soon after), cord flow, placenta function and even my cervix. She didn't want me to go further than 40 weeks, but was prepared to accept my very first scan (at about 5 weeks) which gave a due date of 3 January.

After that, I contacted my midwife and doula in relief to tell them that we were back on track.