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.

A long overdue update!

So it's been a loooong time since I last posted!

I'm now 21 weeks, and all is looking good. Baby is 3 or 4 days ahead on all measurements and - so far - gaining with every ultrasound (which is so wonderful after Sophie, who was always 2 - 3 weeks behind!). I have an anterior placenta, which means that my placenta is in the front of my uterus, something that happens in about 30% of pregnancies. Sadly, this has buffered most of my precious Bean's kicks, so I only feel him/her move when lying breech because the kicks are then aimed lower than my placenta. I have noticed more and more movement over the last couple of days, and I think *just maybe* I'm starting to feel movement through the placenta. It will be a while before I can feel him/her regularly though. Also, we still don't know what gender baby Bean is - the angle wasn't great at my last scan (19 +1) so although the doctor guessed one gender, she admitted she honestly wasn't certain. My anatomy scan is next week Friday at 23 +2, so hopefully we'll be able to see nice and clearly then!

I have also sent off a motivational letter to the hospital ... all local private hospitals have a strictly no doula rule, and I really feel like a doula will be able to help me - especially since my midwife will not allow me an epidural since this is a vbac attempt (which I'm secretly grateful for, since epidurals seem to be associated with decreased vbac success, as well as increased uterine rupture risk).

This is the letter that I sent:

Dear XXX (Client service manager)

I had my first child at XXX Hospital on 10 February 2012, a failed induction turned caesarean section which I found bitterly disappointing. Since then I have been researching and hoping for a vbac. I am now 21 weeks pregnant with my second child, and hope to give birth at XXX Hospital again in December. I am seeing Sr XXX (midwife) and she has advised me that XXX Hospital does not usually allow doulas to be present during births.

I feel very strongly that a doula would help in my case specifically and would like to request that you allow me to have one assist at my birth.

Being a vbac mom, I have a number of added fears and anxieties to deal with, and I really believe that a doula would help make my birthing experience a more positive one than what I experienced last time (due to my failed induction and – I believe – rather unnecessary caesarean, not as a criticism of XXX Hospital).

Research suggests that having a doula present can shorten labour and decrease the likelihood of needing a caesarean section. I will not be using any pain medication (Midwife's preference with vbacs), and doulas can help with managing and alleviating pain in other ways. Also, I am concerned that my husband may need more support during labour than I will be capable of giving him and I would really appreciate the support that a doula can offer to him as well, so that he might feel more comfortable with my labour process and have a better idea of how to support me (rather than the other way around!).

I have spoken with XXX (Doula), a WOMBS-certified doula and she is happy to come in and meet with your staff to discuss how she can help me without hindering their duties, as well as to go through any orientation process necessary.

I appreciate your consideration of my request and look forward to your response.

 

Kind regards, etc

 

I copied the Maternity Unit manager in on the email, and have had a response from the Client Service manager so far, saying that the Maternity Unit manager will get back to me soon. I feel quite positive about my request though - if they refuse me I will appeal higher up, probably with the Hospital manager and even higher up in the XXX Hospital group. The group has an article on their website talking about different methods of pain relief/management, where they even mention a doula as an expert in alternative pain management techniques - plus one of their hospitals elsewhere is used as a doula-training facility.

 

I've also been doing a lot of research into vbacs and caesarean sections, including the various risks of both - hoping to link some on here in the next few days.

Facebook announcement

 

 

 

I'm dreaming of a vbac Christmas

So I obviously didn't start this blog just to write about what's happened already ;-P 

 

I'm currently 13 weeks 1 day pregnant (according to my most recent ultrasound), and expecting our second child in late December/early January - EDD 25 December! What a wonderful Christmas present!

 

It has amazed me just how different this pregnancy has been to my previous one - much more manageable nausea, but it has carried on for much longer (last time I was incapacitated, sitting on the couch trying to keep my insides in one piece but for only 3 weeks, this time its not often worse than uncomfortable but has been around for almost 7 weeks so far with no sign of letting up yet), only one food aversion but many more cravings.

 

And I'm just so much more relaxed this time around. I was so terrified last time that I would miscarry, whereas now I realise that there is nothing I can do to prevent it if its going to happen and although I would be devastated, we would get through it. I'm not reading up on everything that can possibly go wrong. I feel like I'm enjoying it so much more this time! Its so amazing to look at Sophie and know that we have all of that joy and love to look forward to, all over again!

 

This Saturday I go for my first trimester scan. I will be 13 weeks 3 days, and we will let our extended family know and announce on facebook after that. I am a bit nervous - those ultrasounds are always a bit scary, just in case something has gone wrong. But I just cannot wait to see my little bean again!