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!

Beginnings ... Sophie's birth story

My vbac journey started just over 16 months ago when my daughter was born.

I was overwhelmed with paranoia throughout my pregnancy but especially as the time drew near to delivery, and Dr M (my obstetrician) suggested an induction at 38 weeks. I put it off for a week, too nervous to even tell my husband what she had suggested... I don't think I'd even mentioned how terrified I was that something would go wrong! I'd spent months googling every pregnancy ailment, genetic disease and anything else that could possibly go wrong and between my unfortunate new knowledge and the rush of pregnancy hormones, I couldn't control my imaginings. So when she said I could have my baby safe in my arms within a day, contractions possibly slightly stronger than if I went into labour naturally and my c-section risk only increasing to 35% (from 30%), it all seemed too good to be true.

 

In retrospect, it was. If I'd applied half the time to researching c-section rates (and their correlation to inductions) in South African private hospitals as I had to researching anencephaly and sickle cell anaemia, I would have realised that what she was telling me simply wasn't true. And that my greatest chance of having the natural delivery that I so desperately wanted was to simply ask her what other options there were. As in, could I simply schedule a 5 minute appointment with her twice a week until I went into labour, to ease my fears. Or even as simple as to ask her to check my Bishop score before scheduling the induction, to be confident that it had a chance of success (bearing in mind that I was still a couple of weeks short of the average first time gestation period of 40 weeks plus 8 days).

 

Induction - Day 1

So we went in at 9pm, just a day short of 39 weeks and after a lengthy admission process and numerous battles to get the fetal monitor to work correctly, I finally said goodbye to my husband at around 11pm. A while after that, they came in to administer my 'teabag', which was supposed to begin ripening my cervix.

 

After a night of very little sleep, I woke up with cramps in my legs rather than my uterus, and little change in my cervix beyond a slight softening. I started walking (marching!) the hospital corridors as soon as I woke up, to try and get my contractions going, and managed to get them to the point where I needed to pause for a moment as a new one started, but they never became regular. Later on they moved me to the delivery room, and a midwife gave me a medicine to drink (I asked what it was at the time, but the medicines are the one part of my story that I cannot remember) every hour for 4 hours. The monitor showed that my baby was still doing fine, and my contractions were peaking in the low 90s (apparently they should reach up to about 100). However, for every 'good' contraction, there was another one that was in the 30s or 40s - they never reached any semblance of regularity, and despite their intensity at times I was never in any kind of pain. The Braxton Hicks I had had for the past 4 or 5 weeks felt like they were doing more than these contractions!

 

As the day wore on, the previously upbeat midwives became a bit more somber as each cervical check revealed little to no change. A couple of them came in together around mid-afternoon, to check on me. I was still excitedly waiting for 'real' labour to begin, and quite happy to go run a marathon if thats what it took! However Dr M had said to me that TODAY I would have my baby, because I was now 'on the clock'. So we all knew that she would want to book a theatre slot by early evening at the latest. The midwives reassured me that my baby was strong and had a good heartrate, and encouraged me that if I still felt able, I could ask to continue with the induction tomorrow. So when Dr M came in to check on me, they came in with me and helped me to stand my ground, and she 'allowed' me to try again the following day. I was so desperate to have my normal delivery.

 

Looking back, I am horrified that I put such blind confidence in her! I felt as though I were a schoolgirl and she were allowing me to skip a class!!

 

Induction - Day 2

During the night, a midwife came in to insert my next 'teabag' - no good news, still just a fingertip dilated. So I slept as much as I could and as soon as it was light, I began walking the corridors again. I was determined that today was the day! At 8ish I realised I needed to get back to the maternity ward for breakfast and as I arrived I was met by a nurse, "Where have you been? The doctor's been trying to get hold of you. She's not happy, she's taking you into theatre soon so we need to get you prepped". My world dropped. I can still vividly feel that shock and disappointment, and horror at the thought of what was coming, and I have tears running down my cheek as I type this.

 

I phoned my husband in floods of tears. "They're taking me into theatre and I don't know when but I know its soon. Can you get here soon? I need you!". The poor man had been working late the night before and was woken by my phonecall - and I'm not sure how much sense I was making! But to his credit he arrived there within 20 minutes and my mom was shortly behind. The nurses prepped me and tried to lift my spirits, but I was already in the OR when I realised that, at the very least, my baby was coming today and I needed to cheer up. Despite my sadness, the most exciting event of our lives was about to take place.

 

... and Sophie is here!

The operation itself was unremarkable. The spinal went in fine and worked perfectly and the anaesthetist was a wonderful narrator, telling me what was happening and when Noel needed to get ready to take a photo. It was a little uncomfortable while they were tugging, but that was more the thought of what they were doing than the actual physical sensations. All of a sudden I heard a cry and realised that my baby was there. No big announcements; I had to ask to check whether it (she!) was a boy or girl. It was all quite routine and anticlimactic. Noel went with her as the paediatrician checked, suctioned and swaddled her, and then they brought her to me for a brief moment. I caught a glimpse of her out of the corner of my eye as they held her on my shoulder, all 2.926kg and 47cm of her.

 

It was all very surreal and she really didn't feel like she could possibly be the baby I had been talking and singing to and falling so hopelessly in love with for the last 9 months. She felt totally foreign, as if they had just handed me a stranger's baby. To make matters worse, they then rushed her to the nursery to get cleaned up while I was being stitched up and I was then forgotten in the recovery room for 20 minutes until a maternity ward nurse finally remembered to fetch me. By then it was almost visiting hour and so I was not allowed to see Sophie or begin breastfeeding her. Noel came through to my room to show me a couple of photos, and then went back so that at least one of us could be with her, while my mom sat next to my bed holding my hand, neither of us talking much and both ultra-aware that this momentous event had just happened but I was just so eager to hold and breastfeed my baby, and she was so disappointed that I had yet to hold her properly that we just couldn't find neutral topics to discuss.

 

Eventually visiting hour ended and my tiny newborn was brought to me. She latched with some help (just over 2 hours after birth) and after 5 or 6 difficult weeks (particularly in the first couple of days when she couldn't stay awake for more than a minute or 2) and numerous problems, we are still happily breastfeeding today. 

 

Sophie is now a precious, bright, active, determined, independent, adventurous and very chatty toddler. She has opened my eyes to the true joy of being a mom and my heart now really does live outside my body. I wanted her from before she was conceived and loved her from long before she was born - but nothing could have prepared me for how much I treasure and adore this precious, funny little girl!

 

Postscript: a vbactivist is born

It was while being transferred onto the OR bed/gurney that I remembered reading about vbacs during all my wild pregnant researching, and decided that I would not - could not! - go through this again unless it was actually necessary for my (future) baby's health. I have researched it thoroughly in the past 16 months and my research has made me more convinced that the risks of a c-section are even greater than the risks of a vbac, and that it truly is the safest and best option for myself, my future child/ren and our family.