I am on a steering commitee for a Community Midwives program ( as a consumer rep.)
I am wanting to address the policy currently in place regarding the fact that home births are not allowed for women wanting a vbac.
I am aware that as far as evidence is concerned that uterine rupture is not the highest risk of possible problems associated with a home birth but am getting nowhere with this.
I need to address the policy makers - which I think comes down to getting an Obstetrician to agree to it but need evidence to back it up. When quoting the Cochrane data base I was stared at blankly.
Are there any articles/ studies that you know of that an Obstertrician may have difficulty arguing against.
It was also suggested to me that a good starting point may be to try to get the policy changed initially to women who have already had one successful vbac.
I would appreciate any tips.
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Dr David
Moderator posted 25 February 2001 08:43 AM
Wendy
I know of no study that addresses the question of safety of home VBAC, nor even the VBAC rates in a setting that doesn't include the common hospital protocols of close monitoring or possible interventions like augmentation or operative vaginal birth (vacuum/forceps). One can only speculate how the advantages of familiar environment/carers etc would measure up against the advantages (or disadvantages) of timely augmentation/epidural/vacuum. Of course, planned HBAC should not preclude in-hospital options of care via transfer if they become necessary, but good planning and relationships/trust between the groups of carers and woman would be particularly important.
The Cochrane database rightly puts uterine rupture risks in perspective by comparing the 2.7% risk of needing emergency Caesar for other reasons with the 0.09 to 0.8% risk of rupture. Three sentences later, A guide to Effective Care in Pregnancy and Childbirth (ECPC) says "Any obstetrical department that is prepared to look after women with much more frequently encountered conditions…..should be able to manage a planned vaginal birth safely after a previous lower segment cesarean section". These paragraphs would not seem to be supporting a proposal for HBAC.
On homebirth, ECPC states "Several methodologically sound observational studies have compared the outcomes of planned home-births (irrespective of the eventual place of birth) with planned hospital-births for women with similar characteristics. A meta-analysis of these studies showed no maternal mortality, and no statistically significant differences in perinatal mortality between the groups…. Significantly fewer medical interventions occurred in the home-birth groups.." And later "Women who have no factors that contra-indicate a home birth, and who prefer a planned, attended home-birth with facilities for prompt transfer if necessary, should not be advised against this". I must assume that "factors that contra-indicate home birth" would include previous Caesar.
Bastian, Keirse and Lancaster (http://www.bmj.com/cgi/content/full/317/7155/384) in their (controversial?!) paper on homebirth in Australia conclude "while homebirth for low risk women can compare favourably with hospital birth, high risk home birth is inadvisable and experimental". To be completely accurate though, VBAC is not specifically listed as "high risk" in their paper.
I'm not aware of international data on HBAC from countries like New Zealand and Holland where homebirth is a more common option than in Australia. You could contact groups there.
I am not surprised that the policy-makers for your program find it difficult to include women with previous Caesar. It would require an acceptance that this would be an experimental option of care, given that there is no evidence on safety. Experimental options of care, or clinical trials, are of course offered in hospitals all the time, but they require extra counselling and ethical safeguards.
The group of women who have had a caesar followed by a vaginal birth have the lowest rate of rupture (one in 500) and the highest rate of vaginal birth (93%). These were reported experience in the hospital setting. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11084564&dopt=Abstract http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9790374&dopt=Abstract
Wendy, you asked about tips &endash; I'm not sure I have any.
As with all aspects of childbirth, women should be free to make fully informed choices based on the best available evidence. The woman will make her choice weighing up the risks and benefits of options depending on her own circumstances, her own beliefs. Professionals have a duty to respect the woman's wishes and support her whatever she chooses to do. Program directors often have a responsibility to steer a middle course in new programs using public funds to ensure continuation of that funding. A detailed consent form that specifically recognises a woman's right to choose a place of birthing, and that recognises that such a choice may delay emergency care in the rare event of scar rupture could be a way forward. Birthrites may be able to help with advice on such a consent form.
Dr.David
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This advice is of a general nature to help in decision-making. It
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