My friend (who incidentally were pregnant as well) asked me to write something on the issue. I decided against it initially as I do not wish to aggravate the family’s grief. What changed my mind was seeing people in online forums openly downplaying the risk of mothers with risk factors such as previous multiple Cesarean sections. These people go about telling other mothers that there are many mothers who had their birth/VBAC at home successfully. By doing so, mothers were influenced to do the same as they were reassured by other people’s successful experience that it is a safe option.
I do not advocate mother’s making birthing choice based on other people’s experience. Every mother’s body and each pregnancy is different. When making birth choices, you need to ensure you are well informed of pros and cons of your options. You should not be making decisions based on what happened to others because every birth or pregnancy carries a different risk.
What is birth risk?
Mothers always ask doctors about the possibility of certain events happen to them during birth/pregnancy. The thing is, a doctor is not God or a shaman that can see the future. What a doctor can do is tell a mother what is the risk or the probability of an event that can happen based on what has happened before. For example – mothers who want to attempt trial of labour after one or more Cesarean section – what a doctor should tell her is the probability of successful vaginal delivery, possibility of adverse outcomes like the death of a baby or mother having problems that necessitates medical interventions. A doctor should explain to their patient/client about what will be done in the event of complications. A doctor needs to explain the risk of the medical interventions used and the indication of the interventions. All these explanations needed that doctor to know the evidence that supports their advice.
For example, a mother with two previous scars wants to know how much is the possibility of her having a successful VBAC. Based on S Tahseen et all meta analysis – a doctor can tell her that she has 71.1% chance of having a successful vaginal delivery. But at the same time – there are 1.36% chance of having uterine rupture with 0.09% risk of death in the baby.
When a doctor says 1.36% or 0.09% risk – it might sound like it is very low risk. But if I tell you that it is equal to 1 case of uterine rupture for every 100 mothers who are doing trial of labour after 2 previous Cesarean sections – would you feel the same? If I tell you that 9 babies out of 10,000 of these births died? Especially the fact that a doctor cannot tell who is that unlucky one case out of one hundred mothers or 10,000 mothers who can and will develop this complication.
That unlucky one out of ten thousand cases can be you. We always hope that it would not be you but the truth is, we can never know. Doctors are humans with human capabilities and knowledge. That is why, for mothers who have higher risk of getting these problems, we advise them to give birth in hospital. Because if that problem happens in the hospital, you can get help fast to save yours and your baby’s life.
It is like driving in a car everyday. If you have a car who have had problems before, they can have problems again. We know that the probability of these events to happen can be exceedingly rare. Unfortunately, because these events are so rare – we would never exactly know when the car will get into these problems. For example, a car engine can catch fire but you can never know exactly when that can happen. But in the rare event that your car engine does catch fire, wouldn’t it be safer for you to have your car catch fire in front of the fire station with a fireman standing by instead of having you trapped in a burning vehicle 15 minutes away.
You can always argue that the fire station is nearby and just a phone call away. But in a life threatening emergency – that 15 minutes can make a difference whether you come out alive or not.
For majority of women, natural vaginal child births are safe. Knowing birth risk should not make you fear birth. But by knowing about child birth risk, you will be motivated to learn more about birth and how to aim for safe natural birth. By knowing birth risk, you can be in control of your birth by making informed choice on the mode of your delivery and location of birth. By knowing the risk of bad complications of your birth option, you would be more aware when problems arise thus able to recognise it as well as to act on it.
A common misperception that mothers have are the fact that the doctors gives them no choice in the matter of their births. They believe that high risk mothers totally cannot have vaginal delivery in the hospital and they have to do an unassisted childbirth in order to have that natural child birth that they want.
A doctor cannot force you to do a surgical birth but can advise you when the need arise. You can refuse a Cesarean section. You can refuse an episiotomy. You can refuse a bilateral tube ligation. You can refuse to come for induction. You can refuse all these but you also need to understand the risk and possible complications that can happen because of that action. You need to be aware of what the possible risk that your action may lead to. Doctors are not trying to scare you into following their advice. We want you to know all these risk so you can make an informed choice and also take precautions in the event that bad complications happen.
For example, the doctor saw heavy meconium after your membranes rupture implying that the baby can be in distress. The doctor offers Cesarean section to the mother. His or her assessment of the baby being in distress may not be accurate. Still, most doctors would decide to err on the side of caution. Better deliver the baby now before the baby becomes more distressed or worse, die in utero. Mother refused and insisted to continue with vaginal delivery. The doctor has to respect that decision. If labour continues and baby ended up well, then it is ok. But if the baby comes out blue and not breathing?
For a mother who chooses to give birth at home, they should be aware of what is the possible risk of that decision. By knowing the risks and possible complications that can happen, they can take precautions and learn birth techniques that can minimise birth complications. By being aware of the risk of unassisted child birth at home, they should seek a trained provider to be on standby in the event they need urgent assistance. They should be making backup plans in the event that they need a hospital transfer.
No mother wants to make a decision that would harm themselves or their baby. That is why it is important to be educated on childbirth so when the time comes, you can make an informed safe choice for yourself. Remember, if you do not agree with a doctors’ advice – you can always says no and seek treatment elsewhere. Ultimately only the mother have the power to decide regarding what should happen to their body. A doctor can only advise.
You might learn or hear different or even contradictory advice from other mothers, child birth educators, doulas, nurses, midwives or even some doctors can have different school of thoughts. But my advice to you, have a listen to that person who is going to end up having to fix things when it goes wrong. Ask who is going to save you or your baby in the event something goes terribly wrong. You need to learn to trust that person who are going to be held liable if something wrong happens to you. Because surely that person would not want you to develop problems in the first place because as humans, there are some problems that is beyond our humanly capabilities to fix. In birth, that can mean death – either the mother or the baby.
Choose wisely mothers. The power of making this choice depends on you. Remember, with this great power comes with a great responsibility. You are responsible for your life and your newborn’s life and safety. Your family depends on you to make the right and safe choice. Be an informed mother, know your rights and act on it.
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* Dr Nur Hidayati is currently on her way to becoming an Internal Medicine specialist. She is a mother and is passionate about safe birthing for both mother and child.
* This article was first published on www.mmgazette.com
** The Malaysian Medical Gazette is an online hub under The Malaysian Integrated Medical Professionals Association (MIMPA) for medical professionals to share their knowledge and experience regarding current issues and common problems on healthcare with the community in an easily accessible and reliable platform.
*** The views and opinions expressed in this article are those of the author and do not necessarily reflect the position of Astro AWANI.
