Questioning a midwife about women and risk

I am reluctant to make any broad statements about privately practising midwives and the way each one approaches a professional situation in which the woman has risk factors.  Each midwife, and each woman, is unique.  In fact, that's what the often repeated phrase 'woman centred care' points to: that the care for each woman is approached by her midwife from an individual perspective.

A midwife whose practice is under the regulatory spotlight for events that led to allegations that she has engaged in unprofessional conduct when she agreed to provide homebirth care for women in a risk category* is on the stand, under oath, and quizzed by the Barrister acting on behalf of the statutory body.  Here are a selection of the questions that this midwife may be required to answer.  Perhaps other midwives will take a moment to reflect on how we would answer these questions.

* The 'risk' profile could include, for example, postmaturity, prematurity, birth after caesarean, multiple pregnancy, breech presentation.  

With reference to a woman who wishes to give birth at home, the midwife is asked:

"Do you accept that you have a professional responsibility to inform the woman of risks?"
"Do you consider that after you have informed the woman of risk, such as post maturity, or previous caesarean, that it is appropriate for you to agree to homebirth?"
"Do you accept that homebirth after caesarean (hbac) entails higher risk than homebirth without previous surgery?"
"Do you agree that risks in a vaginal birth after caesarean (vbac) birth are better managed in hospital if they occur?"
"If as you say there are some risks for the vbac at home, why did you not record this in your notes?"

"What evidence do you rely upon for permitting vbac at home?"
"What special preparations did you make for a high risk birth at home?"

"Did the mother lead the decisions about homebirth, or did you give her the green light?"
"Did you consider saying no to homebirth, and sending the woman to a doctor?"
"In your midwifery practice, do you follow the Australian College of Midwives National Midwifery Guidelines for Consultation and Referral (ACM Guidelines)?"
"Do you accept that the ACM Guidelines state that the pathway for birth after caesarean is to at least consider referral and transfer to obstetric care?"
"Do you accept the first guiding principle of the ACM Guidelines, that 'As a primary caregiver, the midwife, together with the woman, is responsible for decision making.'?"
"Do you as midwife accept that you and the woman are jointly responsible for the decision to give birth at home?"
"On reflection, with the wisdom of hindsight, do you agree that you made a poor decision in providing home birth care in this situation?"
"Are you able to give the panel the assurance that if you were faced with a similar situation again, you would act differently?"
"Don't you think that a woman who is more than 10 days postmature, and unable to give birth in a small hospital, is too high risk for homebirth, where there are even fewer resources on hand than at a small hospital?"

The main 'requirement' for homebirth is that the woman is able to labour spontaneously without medical stimulation of labour or pain relief.  Midwives attending homebirth use no drugs to stimulate labour or to ease pain.  The only stimulation of labour available for homebirth is natural processes, such as walking, nipple stimulation, sexual intercourse, and perhaps a special meal.  If a woman who has had a previous caesarean, or whose baby is in a breech presentation, intends to give birth spontaneously, she usually accepts the requirement for spontaneous onset and good unmedicated progress in labour. 

The polarisation of midwifery care into 'planned homebirth with a private midwife' and 'standard hospital care for birth' is in itself unreasonable.

Physiological birth is a basic function of the female of the species.  In our world today we have the opportunity to interrupt physiological processes if we think they are progressing in a way that would lead to poor outcomes.

Consider any other physiological process: breathing, for example.
I breathe because that's what my body does.
I continue to breathe whether I am conscious of the fact or not.
If breathing becomes difficult, this can be a warning sign that prompts me to seek medical attention.

In the same way, a physiological labour will proceed because that's what the woman's body does.
She will continue to labour whether she is paying attention to it or not.
If labour becomes difficult, this can be a warning sign that can prompt transfer to another level of care.

Planned homebirth is 'Plan A'.  The midwife checks the fetal heart, or records signs of progress, or monitors the woman's vital signs in preparation for intervention if that becomes necessary.  The midwife has (or should have) no intention to interrupt the natural processes without a valid reason.  A transfer to hospital, 'Plan B,' is a change in the plan.   There are different rules in operation under 'Plan B' than 'Plan A'.

Effective decision making in labour requires a shared responsibility for the decisions that are made.  The midwife has a certain body of knowledge, and familiarity with the processes, and the woman has other knowledge about herself, her values, and her life direction.  Together they are able to navigate the often unpredictable journey of bringing a baby into the world.  A midwife is not a hired help, employed to facilitate a certain preferred option.  Active participation in decision making protects the wellbeing and safety of mother, baby(ies), and the future of the midwife.

Birth is a highly contested zone.  Our society takes a paternalistic attitude towards birth, through the regulation of the midwifery and medical professions, and the oversight of institutions such as hospitals.  This is good - to a degree.

However, the one who is literally 'holding the baby' at the end of the day is the mother, and she is usually within an immediate family and broader community.  Unless the mother-family-community relationships are broken down beyond repair, the best place for a child to be cared for and to grow is within that network.  A midwife works in partnership with the woman, for the childbearing period, promoting health, protecting wellness, and supporting the development of healthy families.

There will always be aspects of risk that either exist prior to the onset of labour, or that develop during labour.  The midwife who recognises and acts appropriately in the care relationship, and the woman who engages in an intelligent way in decision-making, will have a high level of safety built into their care plan.  There is no safer way than Plan A for a well woman to approach birth.  When complications are present the care decisions become more complex, and the need for medical attention becomes more urgent.  A midwife and woman working together in a trusting relationship bring strength and confidence to the decision making process.



Your comments are welcome.

Questions and answers 2: VBAC

The questions for today are focused on vaginal birth after caesarean surgery, VBAC.

This is the second post in the current series

• about midwives who have (or plan to obtain) Medicare provider numbers 
• about planned homebirth 
• about planned hospital birth 
• about vaginal birth after caesarean surgery (VBAC) 
• about women who have certain 'risk' factors 
• about ... 

I have shaded the 'planned homebirth' and 'planned hospital birth' lines as well as the VBAC line, because the place of birth, home or hospital, is a *setting* - not an outcome.

Women often ask independent midwives:
"Will you be my midwife for a HBAC?", or HBA2C (where H=home, and 2=2, and where, because it's at H, it's obviously V)
(and yes, we use abbreviations freely!)

The only truthful answer is "I have no idea, because it's impossible for me to know where your baby will be born!"


But, what is implied in the question "Will you be my midwife for a HBAC"? is,

"If you are my midwife, 

• are you willing and able to provide the professional services I am likely to need in order to give birth safely at home, and 
• do you have the skill to recognise situations in which you would advise me to transfer to hospital, and 
• do you have the wisdom to guide me?"

Planning VBAC at home is perhaps the simpler option from the woman's and midwife's point of view, because it's clear that in order to give birth the woman and her baby need to be well, at Term, and come into strong labour *naturally* - without induction or augmentation of labour, and without relying on medical strategies for pain management. It's clear that if a decision point is reached when medical expertise, or technology, are recommended, these are accessed by transferring care to the medical/obstetric/midwifery/nursing team in hospital. Transferring to hospital does not mean that the plan for VBAC is given up.

Yet planning VBAC at home may be considered by some to be unreasonable risk-taking.  Midwives attending homebirths are required to comply with various guidelines that have been approved by the regulatory authority, such as the Safety and Quality Framework.[Open this link and scroll down to 'Eligible Midwives'].  The Safety and Quality Framework seeks to ensure that women understand that the midwife has no professional indemnity insurance for homebirth, and requires a midwife providing homebirth services to

adhere to recognised consultation and referral guidelines developed by the Australian College of Midwives (ACM) and to have processes and relationships in place to demonstrate compliance with the guidelines.

The ACM Guidelines list Casearean Section as

6.3      Previous Obstetric history
6.3.11  Caesarean Section
CODE B = CONSULT [Evaluation involving both primary and secondary care needs.  The individual situation of the woman will be evaluated and agreements will be made about the responsibility (medical or midwifery) responsibility for maternity care]

The journey to homebirth for a midwife and woman, using the ACM Guidelines, may then proceed to Appendix A: WHEN A WOMAN CHOOSES CARE OUTSIDE THE RECOMMENDED ...
This process seeks to ensure that the midwife and other maternity professionals are advising the woman clearly, and the woman is making an informed decision.

If the midwife is Medicare-eligible, there are other requirements for collaborative arrangements before the midwife's fees can be rebated through Medicare.  This is the case whether the plan is to give birth at home or hospital.


When planning VBAC in hospital, many of the same issues arise for women who intend to proceed without medical intervention, unless there is a valid reason.  Most hospital guidelines require midwifery staff to obtain continuous electronic monitoring.  The woman in this situation is able to decline, if she makes that decision.  

A VBAC in hospital can proceed with continuous electronic fetal monitoring, epidural anaesthesia, IV fluids, a urinary catheter, forceps or other assistance that is available within the scope of a medically managed vaginal birth. Or a VBAC in hospital can proceed without any of these interventions.

Women planning VBAC in hospital would do well, if they can, to find a hospital that has a track record that demonstrates an understanding of VBAC. When you inquire about making a booking at the hospital, ask if the hospital has a clinical practice guideline or other written document that you can take away to read. Some hospitals have this material on the internet - click here for the Women's VBAC guideline.    This will give you an idea of what you are likely to experience.  Your midwife can help you understand the detail.

Specific questions can be asked of the hospital such as what is their current rate of planned vbac (out of all women who have had previous C/s surgery), and actual vbac. The denominator in the actual vbac rate is usually the number who planned vbac, or who commenced spontaneous labour.  So if a hospital says "We have a 65% VBAC rate" it probably means that of all women with a previous C/S who intend to undergo a 'trial of scar' and commenced labour, 65% had vaginal births." 

The decisions that need to be made in any pregnancy and labour (bac or not) are the same. Plan A. If mother and baby are well, and there is no valid reason to interfere with the natural process, the authentic midwife will act in a way that supports and protects natural physiological processes that lead to safe birth. This includes minimising any interruption or interference with the labouring woman.

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"

Births after Caesarean

Is spontaneous natural labour and birth a realistic option?

The answer, in each case, depends on decisions made during the pregnancy and as the labour progresses.

Most midwives, and many doctors, would encourage women to give birth vaginally. Unless there is a specific and valid reason to avoid vaginal birth, there is no safer way for mother and baby than spontaneous, natural, unmedicated vaginal birth.

What the women said ...

... in their submissions to the Maternity Services Review

The website at which the submissions are posted has a statement:

We have received many personal accounts from individuals. These provide a valuable insight into people's experience of maternity care in Australia and were considered by the Review Team in preparing the Review Report for the Minister.

Today I have taken the opportunity to look at just a few of those personal accounts from individuals, and separated out into themes (not in any particular order). Today's theme is Caesarean births and VBAC. Here are some direct quotes.  Women's descriptions of their own feelings have been highlighted.  The number noted in square brackets [n] denotes the reference number for the submission.

Theme 1: Caesarean births and VBAC

1.1 Cascade of interventions in primiparous woman at a birth centre [515]

For my first child, I was 25 and healthy, considered “low-risk”. I booked into the local Birth Centre at the public hospital (it sounds easy but in reality I was put on a ballot, missed out, then made it in when some poor unfortunate woman was shunted out for whatever reason). I attended antenatal appointments with the same midwife, who I thought was on the same page as me regarding birth. I wanted a drug free, intervention free birth. I was well-informed and well-educated.

However during labour my midwife told me she had to perform several interventions which I had been led to believe weren’t routine in the Birth Centre. These included vaginal exams (VEs), the premature rupturing of my waters, and coached pushing (when I was actually not fully dilated and not wanting to push yet as it didn’t feel right).

It is hard to stand up for yourself during labour, so I did not protest any of these interventions, yet they caused, in a cascade of interventions, my cervix to swell and my progress went backwards. My midwife said I needed an epidural and syntocinon to speed things up, even though that was the last thing I wanted, but quite disheartened I agreed. After getting me set up she then left to go home, which I saw as abandonment. My continuity of care ended there. After a few hours I was at the same point, having apparently progressed no further, and the obstetrician suggested a caesarean. Quite defeated and wanting the whole sorry ordeal over I consented to a caesarean that would have been completely unnecessary had my midwife kept her hands to herself.

1.2 Caesarean followed by a feeling of disconnectedness and a profound sense of grief [538]

I had my first baby by emergency caesarean section in a public hospital after a planned home birth. My main care provider for this pregnancy was a community midwife with the Community Midwifery Program here in Perth. During the pregnancy I felt supported by my midwife in any decisions I made about my pregnancy and birth options (Routine ultrasound, strep B testing, water birth etc), and despite the resulting caesarean section, I felt the continuity of care was extremely valuable in making my pregnancy an exciting event for my family, as were able to create a caring and professional relationship with my midwife, leading to feeling secure as my birth approached.

During the birth I experienced great care at home from my primary and back up midwife, however once we transferred to hospital, their role as my primary care providers was not recognized by the hospital, and subsequently I lost faith in my body’s ability to birth as I received fragmented care from a number of different midwives and at least 3 different obstetricians, all of whom I had never met, and who did not take the time to discuss the progress of my labour with me. My resultant Caesarean section was a traumatic experience, and I was not able to hold my son immediately, leading to a feeling of ‘disconnectedness’ from him which sadly lasted well into his first year.

After the birth I experienced symptoms similar to those which I now believe similar to Post Traumatic Stress Disorder, with an inability to sleep, flashbacks of the anesthesia and caesarean procedure itself, and a profound sense of grief that my experience of meeting my first born child had not been the joyous occasion I had hoped it would be.

1.3 VBA2C [404]

Our first baby was born in private hospital by emergency caesarean after a failed induction. My husband and I were left to ourselves in the delivery room for long periods. When we did see someone they were total strangers, people we had never before met, who came and went as shifts changed. Minimal help with breastfeeding was provided until 4 days later I had a wonderful agency nurse who spent an hour in the middle of the night giving me the support I so desperately needed. The whole experience was very frightening and traumatic. I was subsequently diagnosed with postnatal depression.

During my second and third pregnancies we paid for our own private midwife who was with me during the pregnancy, labour and post birth. Although our second child was also born by emergency caesarean, I had the continuity of care that made all the difference to the experience. She was with me throughout labour, then in theatre, and afterwards she helped me in recovery where she enabled my baby to stay with me and ensured I received all the help I needed with establishing breastfeeding.

Finally, with the support of my own midwife I was able to birth our third child vaginally, without intervention and will never forget the hormonal high and feelings of self respect, dignity and peace that contrasted so starkly with the terror, grief and despair I felt when my first child was born.

1.4 Emergency Caesarean followed by VBAC [516]

I had my first baby in a public hospital. He was born by emergency caesarean because he was brow presentation. ... I had assumed that my care at the hospital would be in keeping with basic tenets of human rights- that I would be treated with dignity and respect during birth. This was not my experience.

During the 13 hours of labour prior to the emergency caesarean I experienced a shift change of midwives and felt that the second midwife wasn’t confident to guide me. I felt that she gave up on me. I remember her telling me that she had recently had a caesarean and that it wasn’t that bad. I had painful internal examinations during contractions. The bright lights and the public nature of the environment made me feel violated. This fragmented care with people moving in and out of the birthing room upset the flow of events.

Once the wave of interventions had begun I felt there was no any other option in that environment than to do what I was told and to be a ‘good girl’. Several professionals told me that I would be risking my baby to try anything different. I was frightened, I felt coerced and patronised by the midwives and the obstetrician. I demanded that I try every other monitoring option prior to the surgery which was my most feared scenario. As a way of trying to reclaim some sense my own power in the birthing process I wanted to have my baby remain with me and I wanted somebody to stay with me in recovery. I was denied both of these. Post surgery I lay on a bed for an hour shivering alone, without my baby. I felt exposed and ashamed. This deeply impacted my confidence and the crucial bonding with my baby and set the conditions for what I now recognise as Post Traumatic Stress after the birth. I believe this was caused by a combination of factors namely a restrictive birth environment. I suffered a deep sense of failure and grief which has only been resolved with my second birth.

I approached the second birth very differently and chose a homebirth. My partner was also very enthusiastic that we try this after the previous hospital experience. In spite of the fear mongering about VBAC and the dangers of uterine rupture my second baby boy was born peacefully at home in the water. My main care provider was a midwife in private practice. During the pregnancy I experienced great support to make my own choices. During the birth I had no internal examinations. There was no sense of time constraints during the nine hour labour. It was on my own terms and I felt comfortable and safe in my home environment. I felt that my midwife trusted in my innate ability to birth and believe this had a very powerful effect on the birthing outcome.

After the birth I felt great satisfaction and reclamation of my own dignity. I believe this was due to the wonderful support provided by my carer and the continuity of care I experienced.

These four accounts speak eloquently for themselves.
Recommendations of the Report of the Maternity Services Review (The Report) include:
"2. That the Australian Government, in consultation with states and territories and
key stakeholders, initiate targeted research aimed at improving the quality and
safety of maternity services in select key priority areas, such as evidence around
interventions, particularly caesarean sections, and maternal experience and
outcomes, including from postnatal care."
The Report trivialised homebirth and stated that "Homebirths account for a very small number of births in Australia. In 2005, homebirth accounted for 0.22 per cent of all births in Australia,28" The Report ignored the many submissions by women who called for greater access to home birth and private midwifery services.

Comments from readers are welcome.