Hospital says No to cesarean

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A NORTH Coast mum who has been told she can't deliver her baby by cesarean feels [that the] Hospital is prioritising policy over people.

Sylvia ... said she was told by an obstetrician at the hospital she could only have a C-section ... in an emergency.

"I just had tears streaming down my face - I couldn't believe it," ..."I feel so powerless and betrayed by the medical system that my choice has been taken away."

Ms Leveridge, who is 28 weeks pregnant, wants to avoid the 20-hour labour she experienced before undergoing an emergency cesarean to deliver her first child.

Her first baby was a whopping 4.240kg and Ms Leveridge understands this baby will be just as big.

... under the Towards Normal Birth policy, the state is aiming to reduce the cesarean rate to 20% before 2015.

Ms Leveridge said she was advised the hospital has to reduce the number of cesareans it performs in line with the policy.

... there are risks associated with cesarean section operations ... the rights of the both babies and mothers have to be balanced out.

"It's not just the mum's choice. It's also the baby's choice as to how the delivery transpires. This is something that is often lost in the debate about how babies should be delivered," ...

"My problem is I have big babies and I just feel like I'm on the same treadmill," Ms Leveridge said.

As I see it, there are four issues here: 1. Fear 2. A previous "big" baby 3. A woman's sense of control over how she will deliver her baby, aka woman-centered care 4. Safety for mother and baby, and the health practitioner's duty to recommend the safest course of action

Fear It is not unusual that this woman would feel so fearful of her upcoming birth: her only experience of labour and birth had been an horrendous 20-hour labour with untold interventions delivered in a model of care that provided limited continuity, and ultimately leading to an emergency caesarean. In my practice, women have only one midwife for the whole pregnancy - baby experience. This model of care has been demonstrated to reduce women's fear, and also promote normal birth. Around 90% women who birth with me experience a normal birth.

A previous "big" baby A "big" baby is not necessarily a concern, and nor is it necessarily associated with a caesarean. The important factor here is whether the baby was always destined to be a larger baby that is able to fit through an ample pelvis, or whether the baby was abnormally large perhaps because of poor maternal diet or poorly-controlled gestational diabetes. Many "large" babies are born normally: these are often babies who have been nurtured with good nutrition in a woman whose pelvis is amply able to accommodate a larger baby. The labour and birth is often rapid and the baby is born healthily and safely. The same cannot be said of babies who are abnormally large because of high circulating glucose in the mother's blood. In my practice, much time is spent with women talking about nutrition; why it is important; motivational tools to remain healthy and fit in pregnancy; and finally assisting them with a healthy eating plan that is flexible and is based on their own unique tastes and needs. The average birth weight is around 3.4Kg.

A woman's sense of control over how she will deliver her baby, aka woman-centered care

We know from studies that a request for a caesarean is based mostly on a woman's fear of labour. The woman in this article was quite justified in her fear: her only personal knowledge of birth was an awful labour culminating in a caesarean, and she sees herself staring down that same barrel, since she again feels that she has a big baby. I often find that women will make an initial request, for example for a hospital birth or an epidural, and through their pregnancy care experience, they grow massively in terms of their confidence, knowledge and trust, such that they are saying later in pregnancy, "Actually, maybe I can do this without an epidural. Maybe if I can labour and birth in the water, that will help and I won't need an epidural." Or, "I know I've been wanting a hospital birth all along, but I'm curious about homebirth and if all's well, I think I might like to stay home in labour." The power of continuity of care - where every woman has only one midwife as her midwifery care provider - is often understated in the literature.

Safety for mother and baby, and the health practitioner's duty to recommend the safest course of action

I've sometimes been heard to say that as midwives, we really only have one job, and that is safety. Women engage midwives for their care because they understand that midwives have a unique skill-set that includes knowledge, experience, judgment and compassion. If women possessed this skill-set, they would have no need for midwives. It is the health practitioner's role to recommend the safest course of action, which in this case is a VBAC. The woman is so caught up in fear from a traumatic previous experience that rationally, she is probably not even able to take any of this in. The woman should be supported, not necessarily to birth vaginally or abdominally, but just supported. Nothing more, nothing less. After working one-on-one with her private midwife, towards the end of her pregnancy, and with a healthily-grown baby, she just might see things differently and agree that a VBAC is the safest course of action for her and also for her baby. To thrust this (VBAC) upon a woman who is driven by an unresolved and justified fear state is unreasonable and shows a lack of compassion. Yes, a VBAC is probably the safest for mother and baby. But fear (and the absence of fear: confidence, calmness, surrender) is the most important driver of birth. Until we work to eliminate fear and instill confidence, we will have high caesarean rates, whether these are chosen by women or recommended by health practitioners.

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