“Once more unto the breach, dear friends, once more…….when the blast of war blows in our ears, then imitate the action of the tiger…”, Act III, Scene 1of Shakespeare’s play, Henry V
Shakespeare had a magical way with words when describing a motivating call to arms against great odds and the fortifications of the French. Those of us who advocate for informed choice, respect for client decision making and human rights in childbirth are in no less a figurative war against great odds and the established fortress that is organized obstetrical medicine. For once again, the ACOG has gone on the offensive against home birth and the freedom of choice.
In their recently released Committee Opinion No. 669 August 2016, ACOG has doubled down on their position that hospitals and “accredited” birth centers are the safest settings for human birth. While paying lip service to informed decision making, they encourage practitioners not to support a woman’s decision if it does not comply with ACOG’s opinion. This is done daily by covert peer pressure and fear of retribution or overtly as with the statement, “The Committee on Obstetric Practice considers fetal malpresentation, multiple gestations, or prior cesarean section to be an absolute contraindication to planned home birth.”
In an era where respect for human rights in childbirth and honoring informed consent have been brought to the forefront by a recent Alabama civil court decision further restrictions on those rights by ACOG just seems absurd. They continue to deny recognition to licensed midwives or CPMs. They are 100% aware that while a Committee Opinion paper is just that, opinion, it becomes policy in every institution and in some circumstances influences lawmaking and thereby limits options. Even when policies “allow” for a choice they are often so restrictive that when an option such as hospital VBAC exists its success is less likely than in the home setting. There has been an utter failure of ACOG and academic training programs to teach the skills necessary for vaginal breech and twin delivery so that option has all but disappeared for women who end up with forced cesarean as their only choice. A local hospital here has gone so far as to create a policy banning vaginal breech delivery despite having an extremely skilled physician who has assisted women with their choices for over 40 years. And now ACOG is stating that those of us skilled in these options, midwife and physician, are out of bounds if we support them in a setting not approved by them.
What it should all come down to is respect for the individual based on her condition and circumstances and life experience. No policy based on the abstraction of percentages and relative risk should really dictate the care of all. Once again ACOG has gone too far. Proper respectful authority deserves consideration but when authority overreaches and becomes illogical and overbearing then disdain is a reasonable tack to take. I should add that when authority defies experience and common sense it must be challenged with evidence to the contrary. And so……a story!
In the movie, “My Cousin Vinny” we learn that Vinny did not pass the bar on his first attempt. Nor did he pass on his second. In fact, for Vinny, six times was a charm. I have been assisting women with home birthing now for six years. And in all that time the learning never stops. Contrary to ACOG’s current opinion statement, in those 6 years I have assisted with 34 sets of twins, 51 singleton breech babies and 38 TOLAC. Of course not all were successful at home but over 80% were. In many practices in my local community all123 of these women would not have been given a choice and been skewed or coerced into a surgical birth. I present this data because with each client I was able to individualize her care based on her desires and medical decision making that looks carefully at each circumstance and is not assembly line. The freedom from silliness is refreshing. I continue to encourage my physician colleagues to consider it as an alternative to Big Brother. What I have learned about normal pregnancy in these last 6 years dwarfs what I leaned in the 28 before that. And then just when you thought you had seen it all along comes Denise.
Denise and her partner are both nurses working at a local hospital. Ironically, she had concerns about giving birth in a hospital. See “Why Not Home”. Well informed, she was pregnant for the first time with twins and still wanted a home birth. Her sister had given birth to twins girls at home a few miles away two weeks earlier. Needless to say, options for her wishes were limited. She had been receiving prenatal care from a local HMO and all was going well. She transferred care when she began to realize that none of her desires were likely to be respected. The pregnancy was unremarkable with concordant mono-di twin boys, on the smaller side with normal labs and negative GBS. At 36 1/7 weeks she calls to tell me she is leaking small gushes of clear fluid but no cramping.
In my experience 90% of term pregnancies with SROM will go into spontaneous labor within 24 hours. Not for Denise and her vertex/vertex babies, though. So much for experience! Not on the second or third day either. No, for Denise, six days was a charm. Throughout the week she and her partner seem very calm and trusting of her body. Medically aware of the signs and symptoms of problems she alertly kept watch. Rupture of membranes was confirmed. On the third day we tried Blue and Black cohosh, Cauliphyllium and breast pumping. Crickets! Her body wasn’t ready. My team and I made daily visits to check on the family. Portable ultrasound showed low but adequate fluid and biophysical profiles consistently 8/8. Over the next couple of days came a lot of resting, fluids and intermittent breast pumping and still no labor. Options were discussed and included transfer of care back to the hospital. At this point the team and I were reaching beyond our comfort zone. Partially because we were all constantly on call for days now and growing impatient. But Denise’s confidence and demeanor were reassuring.
I have had clients who have SPROM in years past very prematurely who have remained at hospital or home bed rest for weeks so I knew it can be done. But, knowing the prevailing attitude of ACOG and academicians that near term they see only disaster by not intervening and would jump on the antibiotic, induction or cesarean road we did feel a bit of pressure. Finally on evening of day 4 she agreed to a vaginal check and possible membrane sweep. Her cervix was 5cm/completely effaced/+1 station. A sweep initiated a little bleeding and a contraction and then…..nothing.
Day five and even Denise was getting a bit weary so she finally agreed to a castor oil concoction that she had resisted for days. Voila! About 7 hours after drinking what she said tasted like, “Hell on crack!” real labor began. The team arrived and set up. Babies were excellent and mom’s vital signs perfect. The tub was filled and a very vocal mom shouting. “C’mon baby, fly the fuck out!” climbed in. After nearly 143 hours of ruptured membranes and only 5 hours of intense contractions baby Matthew was born in water. Baby David, not wanting to be alone inside let mom know it was his turn and 13 minutes later he joined his brother in the arms of mom, dad, grandma and sister.
So, was this a birth outside the norm? Of course, it was. Should anyone have the right to dictate that this choice is absolutely contraindicated? Of course not! This family has a story to tell and it is their story. Not the story dictated to them by a distant organization or a hospital policy. My readers all know by now how meaningful childbirth is to a woman and her family. The point should be how we get more practitioners to rediscover the joy of birth and compartmentalize their anxiety. If ACOG is going to continue to promote the medicalization of and intervention into the birthing process and treat women as if they are hapless incubators then ACOG will and should become more and more obsolete. I’ve said it a thousand times but we need to bring back the training of breech and twin birthing so that if ACOG wants to condemn them at home at least women will have an option at their hospital. But their opinions and guidelines are leading to fewer choices, unreasonable policies and even bans on options that their opinions approve of in defiance of common sense.
So, once more unto the breach as birth choices are a human rights issue. How we give birth matters and is worth defending. It’s time to imitate the tiger. Congratulations to Denise and her family and thank you all for the trust you have shown us.