Saturday, August 6, 2011

A scarred uterus

The Australian College of Midwives (ACM) has released an Interim Homebirth Position Statement for comment.

The ACM Interim Guidance for privately practising midwives providing midwifery care for a planned homebirth state:
"There are some contraindications to a planned homebirth which women should be informed of at booking. These are:
• Multiple pregnancy
• Abnormal presentation (including breech presentation)
• Preterm labour prior to 37 completed weeks of pregnancy
• Post term pregnancy of more than 42 completed weeks
Scarred uterus"

While the first four: multiple pregnancy, abnormal presentation, preterm labour, and post 42 weeks' would usually, in most midwives' practices, be triggers for a midwife to advise at least obstetric review with consideration of transfer of care from planned home birth to planned hospital birth, many women in our care have planned and achieved home birth after caesarean (HBAC) - after a scarred uterus - without complication. Many others have made informed decisions to move from planned home birth to hospital care, with the continuous support of their independent midwife, and have achieved what can only be described as optimal outcomes for mother and baby.

As in all maternity care, there are no guarantees about outcomes. You probably know of situations in which better outcomes might have been achieved with a different set of decisions.

The only way in anyone’s book to approach vaginal birth after caesarean (regardless of the planned place of birth) is spontaneous onset of labour, which usually means at home, quietly and privately. The optimal situation as far as I can see is that the woman is able to call her midwife who will work with her in either setting – home and hospital. By 'black banning' the scarred uterus from HBAC, it is likely that some women will feel they have no option but to go it alone, or to engage unskilled help, with sometimes tragic and avoidable consequences. One part of my motivation in writing this blog today is my deep sadness for those women, babies, and families, and the midwives and other health professionals and community members who have had parts to play in these cases.

Dear reader, please take a deep breath, and read on.

There is a further layer in this discussion to which I need to draw your attention.
The Interim Guidance document states that, in relation to women who fall outside the boundaries of this position statement:
"Following documented discussions and appropriate consultation and referral as may be indicated, a midwife has the right to decline to continue to provide, or to accept, midwifery care if it is felt that this would require the midwife to practise outside of the midwife’s scope, skills and competencies."

What does this mean?

How would this new 'rule' apply to a privately practising midwife who is asked to attend a woman with a scarred uterus, for planned home birth?

Midwives need to consider the ethical consequences of this proposed new rule. Of course, from time to time, a midwife and a woman may reach an agreement that they are not able to continue care - this is very different from the new rule which gives the midwife the right to abandon a woman in her care.

At present the only place a midwife has the authority to attend women for birth is at home. We must remember, however, that there is no insurance exemption for midwives who attend women privately in the capacity of a 'support midwife' for planned hospital birth. Midwives in private practice are exempt from the requirement for professional indemnity insurance when attending home birth.

ACM has requested comment on both the interim position statement and the interim guidance for privately practising midwives by close of business 23rd September 2011.
Send submissions by email to or by post to PO Box 87, Deakin West ACT 2600. Only submissions with identified senders and a return address will be considered.


ACM was contracted by the Commonwealth to develop the Homebirth Position Statement for the NMBA.

ACM state that they have conducted a targeted consultation with key stakeholders, including Maternity Coalition, APMA, and Midwives Australia. The ACM branches were also invited to provide feedback on the draft document. MIPP also provided feedback, outlined at this blog post.


Beetle Bugz Australia said...

I would hope that all the private practicing midwives (Who read this blog or not) would not accept the ACM's blanket ban on HBAC.

I am a mum who is trying to conceive a 2nd baby with one of those "faulty" and now "scarred" uteruses. If I enter a hospital I will almost certainly be cut open again. Problem is, I can't step foot in those places, but my desire for my husband and to grow my family is greater than I can bear. I know that my first Caesarian was un-necesary and that my body is capable of bearing a child naturally. The only way I can achieve this though is a HBAC.

However, I feel that it goes against my basic human rights to deny me a trained and prepared professional in my circumstances as I labor and give birth at home. The easy and safe delivery of my child may be marred by a simple PPH and without a trained medical person who is allowed to be prepared with the essential Oxytocin shot to stop the PPH present.

Would the AMA abandon me so in my moment of need? Doesn't this go DIRECTLY against the AMA's aims of supporting women in their choices? I have been abandoned because (for some as yet to be declared motivation!) the other powers that be would rather see me fail in a hospital setting ("See! We told you you can't do it!") than to allow me the chance to labor and birth at home and have a positive and empowering birth that sets me up for a positive and healthy (mentally as well as physically!) start to my relationship with my next child.

And before people get all snippy and tell me that it is about a healthy baby as well as a healthy mum, let me remind you that a healthy baby (which I DIDN'T get from my first C-section where my son was injured!) isn't worth squat if the mother can't care for it physically and on the other levels a baby needs care. Worse still if she really can't handle life at the time and commits suicide... the TRUE leading cause of maternal morbidity.

Joy Johnston said...

Thankyou for this comment BB.

I would encourage midwives and women who have concerns about the new ACM guidance and interim position statement on homebirth to write a response to ACM before 23 September.

The language of these documents is strongly defensive, as though our College is setting out to defend its members against women in our care. There is a curious statement, speculating on the possibility that “In the event of a woman making her own decision/s ...”
This statement made me stop and think – a woman making her own decision/s – isn’t that what usually happens???
Oh dear!

For further discussion go to