ļ»æEpisode 162 - Creating a great birth after previous caesarean
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
Mel:
[0:24] Welcome, everybody, to today's episode of the Great Birth Rebellion podcast. Today, I've got Dr. Hazel Kittle with me, who is a long-term friend, research colleague. She is a midwifery lecturer at Western Sydney University, as well as so many other things at Western Sydney University, not just a lecturer. She has been the lead researcher on the BEST study, which is all about women's birth experiences, but her historical research career has been in VBAC. She's written multiple books about VBAC and we're going to talk about one of those books today as well as a whole gamut of other things around vaginal birth after cesarean section. But if you talk to Hazel, she will remind us all that vaginal birth is not the be all and end all when you're planning your next birth after cesarean. So her books are aptly titled Better Birth After Cesarean. That's what we're aiming for. not necessarily a vaginal birth, we want a better birth after previous caesarean section. Welcome, Hazel, to the Great Birth Rebellion podcast yet again, because this is probably the third time I think we've had you on the podcast.
Hazel:
[1:34] I think it is the third time. Thank you for having me back. I always love coming on here.
Mel:
[1:37] Oh, welcome. We're going to jump straight in because I'm very excited about your new book, which is called The Clinician's Guide to a Better Birth After Caesarean, and it follows your original book, Better Birth After Caesarean, which was more geared towards women. And we have in the show notes below, I'll link all the episodes that Hazel's ever been on. So you can, you know, VBAC is your area of interest or Birth After Caesarean is your area of interest. You can click through and have a look at our previous episodes. But Hazel, I wanted to ask you, where did your interest in VBAC come from? Why has this been the topic that you want to publish books on?
Hazel:
[2:17] Well, very simply, in research terms, we'd say I've got a lived experience. So basically, I did it. I don't feel like I knew much about VBAC. In my training, there wasn't a lot in midwifery about VBAC. It seemed to very much fit into the doctor's area, like it was high risk and scary, and we don't see much of it. But straight after, I qualified as a midwife. I got married. I had my first baby, who was a planned home birth, but ended up being breached and not having any. Back then, in 2007, there was no real support for breached vaginal birth. And so he was a cesarean. I struggled a lot with that. I thought, well, in another couple of years, I'll figure it all out and got pregnant so quickly. That was not the plan. I think we were still newlyweds. It was not the plan to get pregnant so quickly. Within four months, I was pregnant. I didn't know for another few months because I was still breastfeeding. I had no idea.
Hazel:
[3:16] So then I suddenly had this extra pregnancy and I just thought, with that small interpregnancy interval, there's no way anyone's going to support me. And I just read some research and I presented that to my husband and said, you know, this uterine rupture rate goes up. I can't do this. And he just flipped it for me and said, look, it's still very low risk. It's more dangerous to get in the car and drive to the hospital. So I went for feedback. And I did various things to achieve that. Again, it was a planned VBAC at home, but my support team then couldn't be there. So I transferred into hospital and had a VBAC in the hospital. And I fought a lot during that labor. Like it was crazy, the things that I was told, what I had to go through, and just the constant fight the whole time. And they knew I was a midwife.
Hazel:
[4:05] So they trained me. They knew I was a midwife. And yet I still had to constantly battle. and I was told that my cesarean would be at five o'clock. You know, I kept saying, but I have to consent. No, your cesarean will be at, no, sorry, four o'clock. Four o'clock, we're wheeling you off to theatre. That's what I was told. And I just kept fighting it and fighting it whilst trying to be in labour at the same point. And then I did push my baby out of my vagina and her time of birth is 4 p.m.
Mel:
[4:34] Yeah.
Hazel:
[4:34] Yeah, so they weren't going to be able to wheel me out there when there was
Hazel:
[4:36] a baby coming out of my vagina. So that experience left me with a few questions. One was, how does anybody else do this? And I was a midwife with midwifery knowledge and I still had to fight the coercion, the violence and everything that was involved in my labor. How can any other woman do that if they don't even have that knowledge? And secondly...
Hazel:
[5:02] I felt amazing. Like I just felt like I was the strongest woman on this planet. There was nothing that could compare to it. And I'd had a lot of challenges with my first pregnancy, which ended up with cesarean, three admissions in a very short time with pneumonia during pregnancy, then the cesarean, then endometriitis. So mentally, I wasn't in a good space straight after that birth. And for during that pregnancy, the second pregnancy as well. So then this kind of just like healed so much and I just felt so better to be able to be a mother and better to be able to parent these two babies that were now like or more or less twins with only 12 months between them and I wanted to know did other women feel like that was that just because I'm a midwife just because I came from a lineage of midwives in my family is it just because I'm just a bit of a birth nerd like so many of us are and I was you know I knew the home birth community was it because I was tapped in with that and so those two questions are really what drove me and then I had a meeting with somebody that we both love and adore which is Professor Hannah Darling she heard me speak about my story at a community event and then she had recently moved to Western Sydney and was then encouraging me now maybe you should do you should do some research in this and and then that started off my my research career.
Mel:
[6:21] So you experienced what it was like to try and have autonomy during your next birth after your previous caesarean section.
Hazel:
[6:31] Yep.
Mel:
[6:32] Realised how incredibly difficult it was, even though you were a midwife at that hospital, you had the knowledge, you were in, if anyone was in a position to make this work, it was going to be you, but it was still so difficult. Why is it so difficult for women to plan their next birth after caesarean section? What are they up against when they engage with hospital systems?
Hazel:
[6:59] Well, they're up against a risk-based system that was rather focused on this small risk of uterine rupture than ever told them about the risks of repeat caesareans. And within the hospital system where maternity sits, it's all about reducing risk and trying to plan everything that you can. Even just in general health, I'd rather have elective surgeries than emergency surgeries. Right? like we would prefer to plan things and people are happier when they know when things are going to happen so when you've got this then situation where a woman could have a repeat cesarean or a planned provisional birth that then is unplannable and then there's a big push to go I think one of the reasons is to push it towards the control you know that we can control the risk You know, we're very safe with caesareans and we can do this. And then the VBAC is seen as this really ugly, scary, unplannable, we don't know what's going to happen. You could explode, you know, situation that clinicians can't control as much. I've been in this space of VBAC, like how old is my youngest? She's just about to turn 17. And I still actually completely can't answer that question because the more
Hazel:
[8:19] I learn about it, it doesn't make any sense. I don't know. You're all just nuts. Like, why can't you do it? Like, you're crazy. Seriously, why not? It's a vaginal birth.
Hazel:
[8:28] We've been doing that since however we came onto this planet and had females and birthed vaginally. That's how we've always done it. Why is it now suddenly so difficult to do?
Mel:
[8:41] I think you hit the nail on the head that the system is not comfortable with uncertainty and there's uncertainty around a planned repeat cesarean section when you've had a previous cesarean section. The risk factors are relatively known, but there are, so there are both risks to planning a vaginal birth after cesarean section and there are risks to having a repeat cesarean section. What I've noticed is that clinicians are very keen to focus on the risks of attempting a vaginal birth versus the risks of having a repeat cesarean section. And part of the reason I think, this is my speculation, is that if you're having a vaginal birth after cesarean section, it seems like a fairly unacceptable approach in this modern medical system. And so if something doesn't go to plan or if something eventuates that everyone was frightened of, so say, you know, a big postpartum hemorrhage or a uterine rupture, then there's a lot of finger pointing. is C, you shouldn't have done that. But if something doesn't go well in a cesarean section, then we sort of go,
Mel:
[9:54] well, yeah, we all know there's accepted risks with a cesarean section. We're willing to accept the risk of that. What's my question?
Hazel:
[10:04] Well, I will just quickly say as well, the other impact into why repeat cesarean is the more common and the most supportive, I would say method of birth after cesarean is a big historical aspect as well and I've I've I had a real deep dive into the history in this next book which I've really enjoyed going right back to the the quote of once a cesarean always a cesarean which is over 100 years out of date and I mapped that on why it's out of date and where it should have got kicked out and it wasn't it was just held on to even though the science went went defuted it when says it refuted it sorry to say it doesn't shouldn't be that we've kept uh the the system has kept on to that so when you've got that belief that once is there and always is there and which has been around for over 100 years it's embedded in the most powerful uh profession in maternity service which is an obstetrics and then that becomes the belief in the community as well
Hazel:
[11:09] Then it's really hard to change it. So, you know, I'd even hear from women who say to me they have to completely avoid their family. And in one of my studies that was called selective telling, and you would have seen that too in your PhD work, it's being careful who you talk to because actually you're going against what the community believes as well. Even though that's an old, you know, it's a fallacy and it shouldn't actually be used, but it comes from a big history. Yeah, it's really all tied up. It's not just what's happening now. This is something that we've got the legacy of, even though it's been refuted over and over and over again by research. It's hard to budge, and I think one of the reasons it's hard to budge is because it's well supported within that medical community and then it's well supported in society. And so people trying to get in the middle, which is often what midwifery are
Hazel:
[12:01] trying to do to disrupt the system, or women, we're seen as the disruptors. And therefore you're seen as being a little bit radical and then the coercion comes in because if you're not making choices that either the professions or the community agree with, then they've got to use things to try and change your mind.
Mel:
[12:20] So you're saying that historically if you'd had a previous caesarean section, the obstetric community would say, right, that's it, forevermore you're having caesarean section.
Hazel:
[12:29] Well, it was kind of wise to do that too because it was a vertical scar and originally they didn't have any ways to suture up the uterus. So, because they just didn't have ways to get internal suturing and then to go in and remove them because there wasn't dissolvable sutures. So I went through the whole history of that, how the cesarean has changed over the years by the introduction of science, you know, new types of suturing. And I will also say I do give a nod to the women who were the guinea pigs for that entire process, which we, myself as someone who's had a cesarean, can be grateful for. I'm actually more grateful for those women that were the guinea pigs who often were made to do that without pain relief and were often women in the community such as black women who were then experimented on to be able to then be the benefit that we've got today. So I do mention that in the book as well because we do have to give a nod to that. It's not just these amazing obstetric men that were doing all this stuff. They were actually doing that on real women and those women often had to suffer for our future benefit.
Mel:
[13:31] So historically when when they were doing cesarean sections the operation and
Mel:
[13:36] the whole process was very different to what we're capable of oh.
Hazel:
[13:39] So different they're incomparable and but it's gone through that just didn't happen overnight like that went through the process and so how it was done originally and why it was done originally is very different to how we do it now yet methods
Mel:
[13:53] So gone are the days where it's once a previous cesarean always a cesarean now.
Hazel:
[13:59] But it's just been latched onto so much
Mel:
[14:01] Right but now I mean you look at the research and even for women who've had previous two or three cesarean sections the research is saying every woman who's had a previous cesarean section should be offered the opportunity to have a vaginal birth next time if that's what they want yeah why are clinicians so resistant because we know that it's in the low percentages of women who want to have a vaginal birth after cesarean actually will get one if they choose to give birth in a hospital. It's a completely different story for women who are choosing midwifery-led care and vaginal birth after cesarean at home.
Hazel:
[14:36] Yeah.
Mel:
[14:38] What's holding clinicians and hospitals back from being more open to vaginal mood?
Hazel:
[14:45] Look, I think it's what is the norm and then what is supporting and what is the culture of the unit that you're then working in whilst you're also trying to deal with policies and procedures and large volumes of people coming through. So I think it's just very difficult in a conveyor belt system where we need to have policies because we need to have minimum standards. Like if we didn't have those, then people could be doing anything. So policies are good to make sure that we reach our minimum standards, but our minimum standards are pretty low right now, right? Let's just have somebody that's alive at the end of it, which is important, but there's so much more to it. So I think it's if the culture is you don't see VBAC very often,
Hazel:
[15:27] then why would you even think it's important? If all you see are caesareans and women having a repeat caesarean, then that's your norm, and that then becomes the women's norm that you're you're then giving advice to and then there's other layers to it because if that's become your belief that cesareans are safe and and you think that the mode of birth doesn't actually matter to a woman because you're not actually meeting women who have had a birth that changed their life because you're doing that in the hospital system that's pretty hard then why would you hold importance to it?
Hazel:
[16:03] So then when you're giving that advice, you know, terms such as, well, you know, if you were my sister, this is what I would advise you to do. Or, you know, I had caesareans, there was no problem with me. And then there can be the woman is coming in with their own family history. So they may have been told, well, people in our family have never had a vaginal birth, which obviously is a lie because you only have to go back on their ancestry family tree to figure out that they must have done. Otherwise, they wouldn't have survived this long.
Hazel:
[16:28] But in their immediate time, they're thinking of their mother and maybe their grandmother and their aunties and cousins, then they have that belief as well. So you match the two beliefs together. And I recently had this. I had a woman contact me recently on social media and she said the same thing. She said that nobody in her family that she knew of had had a vaginal birth and they put that on her the whole time. Yet she just kept fighting it and fighting it and she blocked people out and she kept fighting and fighting and she got a vaginal birth. Now, she has now broken that curse for her future generations because they can't hold on to that now. She did it. Now, if she has daughters, then they have the legacy that actually their mum did do it. And their mum did have a paternal birth. And it's not because we're built weirdly as a family. So, yeah, it's why are they not supportive of it? I think it's because it's not really the normal. more they're not interested enough or don't understand the power of it. And I think this is where it's so different, where you get midwives in continuity of care and especially at home when we do see the power of birth and we can see how healing it can be. We can see how life-affirming and how it can change the course of women's lives because they own that birth and they feel the power, and especially VBAC, it's addictive. And you see that and therefore you're going to fight for it. But if that's not what you're normally seeing, then why would you fight for it?
Mel:
[17:56] So then women who are planning a vaginal birth after a previous cesarean section almost need to be aware that society and mainstream maternity care is not in
Mel:
[18:06] favour of their intention to have a vaginal birth. Certainly the system would prefer that women book in for a repeat cesarean section. It's easier for the hospitals to manage. You know, supporting a woman through a VBAC, I know as a private midwife, is more complex because there's some emotional factors as well and inbuilt doubts that they're not even sure. Oh, sometimes they feel doubtful that it might work for them. But also as a clinician, there are some additional things that you need to be aware of because the woman has a scar on her uterus. We are hypervigilant to detecting if there's been a complication because she's got a scar on her uterus. Do you think that clinicians working in hospitals, and I know this is a very broad scraping statement, Are we taught to be confident in detecting those issues or do you think we're just avoiding learning about VBAC in the hope that more women will just plan a cesarean disease?
Hazel:
[19:09] Well, I travelled around the country and I've done this overseas as well and I do these workshops with clinicians and about how to support birth after cesarean. And I'm very honest when we go into the uterine rupture stuff and we would have a look at what are the different signs that women will show that potentially they're having a uterine rupture. And there is so much ambiguity with it because it could be a million other things that actually at the end of that session, it's like I give them permission, but to be unsure about it because we don't have this cool device. Imagine if we had like on the SCAR and we had like a little, like a loading sign, loading, loading, loading, and then it would just tell you, you're trying to rupture in like, and it gives you a countdown, right? And you'd be like, oh, okay, all right, it's not working. We better go transfer in or go to the, get to the theatres. It's called theatres. We've got X amount of time before we get there. Hurry up, ambulance. We've got this round time. And then we go there and they go straight into theatres. And we do not have that. You know, the triad of symptoms that we expect, the three different ones, can happen for a variety of different reasons and can never actually be related to a uterine rupture ever. And we do not have the x-ray vision to be able to go, oh, I can see exactly what's happening here. So we live in that gray zone. The uterine rupture is part of that gray zone. We just don't know what that is going to be. And sometimes, unfortunately, we get it wrong.
Hazel:
[20:33] And that can lead to not picking up a utine rupture quickly enough. Or it can lead to a repeat cesarean for not a reason of being a utine rupture. And that is the challenge that clinicians have. And I am never saying to clinicians that is easy because I know that's not easy.
Hazel:
[20:51] But you're not in charge of her body to be making that decision. So when you're in that situation as a clinician, you often think you're the only one who has to have that responsibility. Like if it all goes wrong, it's down to me. But I think we need to challenge that because it's actually the woman's decision. And so with that communication, like it should be most definitely the clinician
Hazel:
[21:15] sharing what's going on and explaining that and then the woman still making that decision.
Mel:
[21:20] Yeah, well, I mean, as a clinician myself, I support women who are planning VBAC, but who are planning to do adrenal birth after cesarean at home. And certainly the research around that is that we have a higher transfer rate for women who are planning VBAC because of that uncertainty where there's a lower tolerance from the healthcare provider to be willing to accept some alterations in monitoring. So for example, if I'm listening to the baby's heart rate and it's been elevated for a little while.
Mel:
[21:54] I'm much more likely to transfer to hospital sooner with that woman who's having a VBAC than if she wasn't. You know, sometimes when the baby's heart rate elevates, like, okay, maybe we've been in the hot pool for too long, hop out of the pool. Maybe the woman's a little bit dehydrated. We can try a few things, we can recheck and we can think, okay. However, if that's happening at home and the woman's having a VBAC, I'm immediately thinking this could be an early sign of uterine rupture and I need to transfer sooner rather than later.
Mel:
[22:25] And any kind of abdominal pain during the labor that's between contractions, you start to think, ooh, okay, could that be the scar? Whereas if a woman hasn't got a scar on her uterus, it's like, oh, it's a bit achy. You're like, okay, maybe this is a muscular issue. Maybe we'll try a heat pack. Maybe, you know, we're a lot more suspicious of things like abdominal pain and alterations in the fetal heart rate for women who are having a VBAC.
Mel:
[22:50] Which is why the transfer rate is higher when you're at home and I think rightly so you want to be cautious and I've certainly there's two occasions where that stands out at me that I transferred because I thought perhaps there was a uterine rupture happening and both times we arrived at hospital and 12 hours later the woman was having a cesarean section repeat cesarean section for a confirmed uterine rupture you know both of them were minor everybody was well but I thought wow you know we lucky we transferred those scenarios because what I thought was happening was happening but it like this kind of highlights that it takes a lot more clinical reasoning and a bigger appetite for potential risk than in another birth and I don't think that sits well with maternity care systems because Because maternity care systems have trouble catering to individual needs and quirks. And I feel like VBAC is...
Hazel:
[23:57] Definitely in a fragmented system, definitely. When we've got our contingent care models, I think it's very different depending on who is doing that contingent care model. So I think you've got to focus on whether you've got that continuity and whether the philosophy of the profession doing that continuity is also supportive of, is going to be more supportive of VBAC than not.
Hazel:
[24:19] I remember having a beautiful obstetrician that came along to one of my workshops and, you know, I would just kind of keep challenging them and I'd be like, well, okay, but what about VBAC after two cesareans or what about VBAC with induction and what about this and what about that? And he said, if they're in the hospital that I'm providing care for, the care is going to be the same and we're looking for the same issues and we'll do the same thing, which is go to theatres. Like the level of risk at that point doesn't really matter if this is what the woman wants to do. Mind you, he did a lot of work to get to that point. But it was really interesting that he had finally got to a point that went, oh, a VBAC after three cesareans, a VBAC with an induction, a VBAC with twins. As long as you're, in his mind, he could care for you because he won't do home births. He can care for you in this particular hospital with this particular type of care, which would be continuous monitoring and having a midwife, all these things. This is what he would see. And I really liked how he got to that because he's like, but I'm going to do the same thing. Like I wouldn't do anything different because of this extra risk on top of it. We're still just going to monitor in the same way. We're looking for the same issues. We're putting the woman at the centre. And if we need to transfer,
Hazel:
[25:30] we've got that here. Like we've got the theatres down the corridor.
Mel:
[25:34] Yeah. So then what do clinicians need to know? Because everybody listening, probably, I'm imagining they're listening because they want to increase their confidence in caring for women who are planning a VBAC. So what does the clinician need to know? If you were looking at a clinician in the eye and they said, what do I need to do to support vaginal birth after cesarean section? What are we looking for to help keep this woman and baby as safe as possible?
Hazel:
[25:58] Look, in the book, I use the four factors framework, which is something that came out of my PhD. So those four factors are having control, having confidence,
Hazel:
[26:06] having a relationship and having active labour. And then I dive into each of those. What does having control mean and what can you do to support women having control and a lot of this information was developed and then further developed in the workshops that I've done like I would put information together then I would get more from the people that are discussing so I would learn a lot on what was what do they need to know about these things and so there's some knowledge they need to know like understanding birth trauma understanding obstetric violence this all comes into the control because the opposite is a lot of control so what does that mean so my solution for that is to work in a trauma-informed way and so I dive into that what does that mean to work in a trauma-informed way and I've kind of gone a bit radical by actually giving a step-by-step way to do a trauma-informed bedial examination I mean it's just a it's just an idea but it is you know it is a way to bring a big term trauma-informed care to the practicalities of daily
Hazel:
[27:07] Work in something that is seen by clinicians as so routine but can be seen as so violent by women so I kind of give those kind of practical strategies to kind of go okay this is the issue if it's loss of control this is kind of the solution for it and then this is how you can you need to bring this into your everyday life also how can you get confidence so I mentioned earlier that if you don't know or care about VBAC or you've never seen anyone do it then you're not going to be a champion for it like you're not going to support it so there's ways to do that how to do that like listening to awesome podcasts like the great dress rebellion and but you know given resources to go okay you need to tap into the why and i actually put in there some research i haven't put out before um so this was from the feedback survey where we actually asked women
Hazel:
[27:56] Why why vback and we never got a chance to put that into any of the papers because as you know it's very limiting what you can get into a publication i thought i've got this data i'll just put that in and I'll show how with the content analysis that I did why VBAC was even important so I kind of want clinicians to tap into that and it's a little bit against the narrative that's going on right there's this narrative that every birth matters well yes it does but every type of birth is equal and it's kind of a little bit because I do say it's about the better birth after cesarean but i also think that we can't we must not discredit the importance of vaginal birth with that and that's never to discredit or to make women feel bad if they didn't have that but i think we still need to be be aware of why it's important and why vaginal birth is important so like i've got all that in there with that evidence in there as well um relationship i challenge them on what type of of care do they give you know and to to talk about why of continuity of care is so important so like I put in there about you know what what the different models of care how that impacts women and then if you are working in that fragmented model how not to be a jerk like how to be that really cool person so
Mel:
[29:11] The book is called how the clinician's guide to better birth after cesarean how not to be a jerk.
Hazel:
[29:17] Well yeah basically because if we go back to the control factor as well like I'm telling them like just why are you doing obstetric violence And it's like, for God's sake, stop.
Mel:
[29:26] So you're saying one of the big first things that clinicians need to do is to realize how important it is for the woman to have control over the decision-making process.
Hazel:
[29:36] Yep.
Mel:
[29:37] And, you know, a lot of people say, oh, you can't control birth. Well, you can't control what your body's going to do in birth to a degree, but there is so much that women can control. And so as clinicians, we need to realise that the woman is the key decision maker. That's what it means for the woman to have control, is to actually be the ones making the decisions.
Hazel:
[30:01] So the woman can show that she was in control of her choices, her wishes, her wishes. Her preferences and her outcomes. Because I saw that in my PhD, when women had that control and they were able to feel that they had that control, then even if the outcome wasn't what they had planned and then had a repeat cesarean, they were able to say that they controlled that part as well because they made that decision. Yes. And that's really important. It's when you take that away, then that opens up to so much issue. That control is really important. And what we can do to that, like we can take that away completely by not giving options. And I think just by having a hospital that doesn't support VBAC, we are taking that away. Correct.
Mel:
[30:48] Well, and this brings up a point is that as much as clinicians want to be able to give women control over their choices for their vaginal birth after caesarean, if the clinician's working in a hospital and there's, you know, there's one near us, does not do VBAC. So there's no choice or control for women. If they arrive at that facility, they either get transferred to a different facility or they get given a cesarean section. That's the level of control that the woman or the hospital has over her birth experience. So there's a massive barrier here because, you know, it's all well and good to say to clinicians, well, you've got to help the woman have control over her choices. But there are heaps of barriers for that clinician, they might say, our hospital won't even let them in the door, firstly. And then secondly, there are all of these restrictive policies that don't allow for women to have control over their choices with regards to VBAC. So I just feel for those clinicians and, you know, there's probably midwives out there listening going, I can't, I can't practice in a way that allows women control because there are so many institutional factors that impact on that. What can midwives do to help change the culture and practice within their facility to make it more possible for women to have choices?
Hazel:
[32:08] Start where you can start in what you're doing. So, for example, if you're using a trauma-informed care framework in everything that you do, then people will see that. If that's how you do a vaginal examination, the woman experiences that, whoever's with her experiences that, and what if you've got a student also seeing that or another clinician in the room who sees that because that is throwing a pebble into the water and it will have a ripple effect. You don't just say, I can't do anything. You do what you can do at the level that you're at. And we need everyone at every level to help. We can't only change this as an advice. We need this to be a collaborative approach. But if you don't have that, say you're a new grad and you've just come out and you're just kind of working in this system, then make every interaction with that woman count because obstetric violence actually comes down to interactions, both physical interactions and verbal interactions. And if you are being a beacon of trauma-informed care in every single practice that you do,
Hazel:
[33:13] By listening to women, by hearing about their previous experiences, by advocating for them and going, well, you know, the guideline says this, but they would like to do this. And so we'll support what they want to do because we're still in a safe space of the hospital. We can still transfer and do things if we need to. If you can just start small in your interactions, in the care that you do, you can bring it down just to how are you going to talk to the woman that day? How are you going to listen to her? In fact, is that appointment going to be just you harping on about all the list of things that you've got to be done or actually are you going to start the appointment by saying to the woman I'm so pleased to see you today can you tell me what you want to learn today what's on your mind because that woman has been sitting in the appointment area with a planning a script in her head thinking of all the things that she wants to say to you and then the minute you walk in you kind of go into stunned rabbit mode you might forget any of that information or you don't feel brave enough or given the opportunity to say any of that stuff. So how can we make even just that appointment woman-directed and trauma-informed by putting the woman at the centre to say, how would you like this appointment to go? What do you want to talk about? And she goes and she feels better. And then you can add the extra stuff that you're hoping to talk about that day too.
Mel:
[34:28] And one thing that I often say to midwives, particularly the midwives who are working in internatal clinics, have got an incredible opportunity to give information to women before they get to their birth because it's really tricky if a woman arrives to birth unit and you're the midwife receiving her and there hasn't been all of this pre-work done, pre-education done. So for midwives who are working in the antenatal clinic, one thing that I really suggest to make the communication of information more, I guess, lush and rich, knowing that they might have 15 to 20 minutes with this woman is, yes, first thing, hey, what do you need from me today? What would you like? Start with what the woman wants before you move on to what you need as a clinician. But then also maybe we can have a little fact sheet that you could create yourself as a midwife and just list out some of the great resources, some great information resources that women could refer to as they learn about their options for vaginal birth. And you could hand that to them and say, hey, I've actually got a little fact sheet on vaginal birth after staring. It's a little bit underhanded because a lot of hospitals like to monitor the information that goes out to women. but you could write things down on a post-it note like, hey, listen to this episode of the Great Birth Rebellion. Hey, read this book from Hazel Kittle. Hey, look at this Facebook page. You know, there's a few VBAC Facebook pages that are excellent.
Mel:
[35:56] We can become conduits of information to inform women, hey, at this hospital, you have got a 10% chance of having a baby out of your vagina if you've had a previous cesareas section. You've got to know what you're up against. you've got to know that our policies say certain things and so maybe you need to prepare for that kind of thing also there's some further information here that you can look into by the way if you really really want a vaginal birth after cesarean have you looked into the other models of care that might be available to you in this area for example there's another hospital who has better stats or there's a private midwife in the area who's got a reputation for attending women who have previous cesarean sections. So we can actually present women with a full menu of options. Just make her aware of what she's up against within the maternity care system that you work in. And all of a sudden, she has had a list of choices presented to her that she didn't realize were options before. And that gives women this huge sense of control. She's like, whoa, actually, I have more options than I thought that I could choose from. And even if she still continues to be in a kind of, I guess, a more hostile circumstance, she has an opportunity to prepare for that, to give herself the best chance possible within that system.
Hazel:
[37:18] Because how can you support a woman to have a better birth after cesarean if you don't tell them what the options are?
Mel:
[37:22] Yeah.
Hazel:
[37:23] And I start the book with a story that shows the issue of this. And this was a real story. A woman contacted me and she had been going to a hospital in Australia and going along for appointments. Just as she did, she'd been told about repeat cesarean. And she'd already planned it and been signed off for a repeat cesarean.
Hazel:
[37:46] Not a problem, she thought. This is what I'm going to do. Have a cesarean. That's what I had last time. This is what I do. And then somehow on her feed, my book came up. She read the whole thing in one sitting between one appointment and the next one. By this point, I think she's like 32 weeks. So she's quite far along. She's read this book. She's inhaled it. She's got notes all through. She takes it to her next appointment, slams it down and says, I want to have a VBAC because Hazel says I can. And they turned around and went, sure, not a problem. We 100% support you. Let's do this. So it sounds really, really good, right? That's not good. How does she get to 32 weeks, start a consent form for a repeat cesarean and never know there was another option until she found it out?
Mel:
[38:32] Yeah.
Hazel:
[38:32] And then I kind of think it's a little bit sick that they then support it. If you were that supportive of it, why was it secret scribble business and you didn't tell her about it?
Mel:
[38:40] Well, this is the classic scenario of hospitals offering women the options that they want them to accept. And then they'll, they'd be willing to entertain other possibilities if the woman suggests them, but they won't offer the full menu because they don't want women to choose from the full menu. They want women to choose a particular thing. And so that's what I feel like women are up against with VBAC. And so when you say the one thing that clinicians can do is give women control, a really simple way of giving women control is to list out all the options they have, whether or not they're available within your facility or not is a different story but list them out so you could have a private midwife you could have mgp if that's available you could go to a different hospital you've got to know what we have on offer at this hospital and what's not available to you at this hospital that gives women control when they know the full menu of options so it's it can be a 10-minute conversation.
Hazel:
[39:41] And that's all in that relationship chapter in the book because I think it's not just what's available but it's actually what does the evidence say as well yeah and that includes you know encouraging women to find a doula so that's all in there to explain you know this is what the evidence says about this model and this model and this model in relation to VBAC as well let's look at it in relation to birth after cesarean and so that when that conversation is being had because certainly as midwives our first standard of practice is to give evidence-based care then you've got that evidence knowledge to be able to share with women and if you're not telling them about the options, if you're not telling them about the modes of birth available or the models of care available, then you are breaking your standards of fight.
Mel:
[40:25] So that's step one is control. Yeah. And the second factor you talked about was confidence. So what does that allude to for clinicians?
Hazel:
[40:37] There's the knowledge of what women need with confidence, but actually a lot of the stuff with what women said about their confidence was not so much confidence in their own body because that's really hard for us women to have, especially if you've never pushed something out of your vagina before. So how can you ever believe that? And even myself, I didn't believe I could do that. So that's hard to do. Although I do encourage women to go and learn a lot more about, you know, labor and birth
Hazel:
[41:04] They were more sensitive to how confident their healthcare provider was in them and in their ability. So if their healthcare provider was like, well, you know, you might have a VBAC, but, you know, depends who's on duty that day, depends how it goes, depends if we have that room available, depends what stars are aligned, like, I don't know, depends on the weather, then you're not really exuding confidence to the woman and the woman has taken that on board as well and goes, wow, that person's actually not confident in my ability to even do this. Whereas compared to having a clinician who straight away just says, yes, I'll support you, that helps straight away and then explains all the things that are going to help them. You know, I support you because I believe in you and why don't we look at, you know, how you can be active in labour, that's going to help you and how about we look at, you know, your nutrition during pregnancy because that can really help you and your fitness and brings in all those other things. Doesn't say that they are the only source of confidence for that person because you're not. Sorry, none of you healthcare providers out there are gods. You are not. You may feel like you are sometimes, but you're not. And even as private midwives, we've got to make sure that women that we care for know that you're not an island and there's lots of other resources out there. And the more that you give that knowledge and give that confidence to women, then the more confident they will feel in that they've even chosen the right person.
Hazel:
[42:29] And in the first book, I did kind of throw it on the head and say, actually, you know what, it's your choice who your team is. So go and be critical to that team. Go and ask them what they actually, you know, they deserve a spot on your team. You're not lucky because you got them.
Hazel:
[42:44] And I then try and just turn that around in the second book to go, okay, what can you do to increase your confidence? You know, where is the why? Why do we support VBAC in the first place? Like why is VBAC important to women? Go and learn about that through these stories. And then what do you need to do to build up your own confidence
Hazel:
[43:03] As well build up your own knowledge build up your own bank of the the why it's important in the first place and then how important it is that you're invested in it and if you're not and you don't believe it one probably not going to read the book in the first place but otherwise like step away and give it to somebody else like actually go I'm not the right person for you and it's time for someone else to care for you if you don't feel that you can provide that and that's actually really hard for clinicians to do and on a personal side note with that I did do that once when I moved to take on this full-time job um it was huge this academic job and I didn't know I thought I could still just keep doing I'm finding a bit on the side and I'm super human I can do that but it was getting hard because I've also got a family and I've got a family with unique mental health issues and neurodiversity that actually needed a lot of extra support So then when women would then ask me to be their midwife, and first of all, I'd be really excited because I love that part of my life and that clinical practice. And this woman came on board and she chose me because of my work in VBAC and she was planning a VBAC. And I hadn't even met her yet. She'd made her decision based on my history and my research. And I hadn't even met her. And there was lots of like emails and stuff coming through and organizing when I was going to meet. And I just thought, I just didn't have that.
Hazel:
[44:25] That energy to give and I had to sit back and go you know what she she's chosen me because of what I do but I know a lot of private midwives that do that as well I'm nothing special compared to the fact that there's all these other private midwives out there and it's actually time for me to give that person somebody who can really
Hazel:
[44:46] Embrace them what this person needs is a lot of love and they need a lot of attention and they're going to need that to be able to get to the point where they can confidently have a feedback so i've gone on the phone to another private midwife who just exudes that motherly energy you know and has their own group that everyone can meet up in and is in the area where this woman lived where i was going to have to travel down i thought that's what she needs and this midwife was like are you sure Or are you sure you're having me? And I'm like, no, honestly, she needs your love. And I don't have that to give right now. Obviously, I'm so passionate. And please, I don't want you to feel bad to me, either of you, obviously. But I just want her to get the best care that she can get at that point because I wasn't at the ā I didn't have that in my capacity at that time. And that was ā you know, I think that actually shows more strength and growth as a clinician than just taking someone on anyway because of greed or because of status or because you want to do that and you want to be that all for somebody and sometimes we've got to go as clinicians you know that's not I'm not at it. She had a great time with that midwife had a great be back at home told me all about it sent me messages sent me pictures and I never regret what I did that and I think sometimes as clinicians we've got to go am I the right person to be on that team do I deserve to be on her team.
Mel:
[46:08] So it It was about you acknowledging your capacity at that time to serve that woman. And so in terms of you as a clinician having confidence, it sounds like firstly, you're suggesting that we immerse ourselves in information about VBAC so that we can, I guess, be academically prepared.
Mel:
[46:29] And then it's about clinical preparedness as well, because it's one thing to go, I think VBAC is important. I can see why this is important to women. But how do midwives practically prepare themselves to confidently care for women who are having a VBAC? Because, I mean, I learned from other midwives watching them, and then they would tell me the things that they do and that they're looking out for. And then obviously, I went on my own journey of researching, okay, what do I have to look for? What are the specific things that I should be looking for as a clinician so that I feel confident that things are going well or that it's time to escalate care and change the plan? How can we build clinical confidence once we know that we want to start supporting women having VBACs?
Hazel:
[47:17] Yeah, absolutely. We do need to do that. And that confidence comes from, I think, just being around it as well. You know and so if you if you haven't seen very many v-backs then buddy yourself up with the midwife that does do it or does vaginal birth really really well like ask i haven't seen a VBAC for a while i want to see the why i know when i was working in a tertiary hospital i had a um a a doctor she was a registrar and had vaginal birth herself and then was pregnant again but in the meantime had been working had this rotation and was seeing all the fear around birth and it was kind of freaking her out a little bit and she said can I just come and sit in on one of your births and I just want to see a powerful vagina birth again and I'm like oh well it depends on the woman and only if you promise to sit in the corner and not say a thing unless I say could you please come here now like if you if you say anything like negative you're out um and she did and it was it was good for her to realize that and then she approached me to then be in this hospital
Hazel:
[48:18] Birth together with obviously the woman made the decision that she could be there to begin with um and that helped her she's like okay it's good i've seen a vagina birth again it doesn't all end up in cesareans i'm i'm feeling good and went out and so i think we have to recognize well maybe we haven't been seeing that and actually as as the director of academic programs here at western sydney uni that is so hard for our students to see vaginal births like their birth numbers they're struggling to get their birth numbers with the decline in vaginal birth the increase of inductions the increase of cesareans, and the less staff to mentor them, even in the departments, and the more students that are out there. It's just getting ā well, I had a clinician say to me who teaches at our university. She said it's a bit like Hunger Games out there at the moment to get a vaginal birth, and that's a bit scary. So if they're not even seeing it, Then how can we have confident practitioners when they're coming out and doing it? So that's why we have to model them up with good models of care.
Mel:
[49:17] Well, this is it. So what you're saying is, is on the ground, we're seeing reduction in vagina birth anyway.
Hazel:
[49:25] Yep.
Mel:
[49:27] Hospitals are not going to willingly upskill their midwives to be attending VBACs because it goes against the kind of culture of most workplaces. So it sounds like clinicians, midwives, doctors, students have to be willing to take their own initiative. This is basically self-directed learning that you're going to need to undertake in order to gain confidence around caring for women with feedback. This is not an embedded intention in the maternity care system to upskill clinicians on how to support women to have vaginal birth.
Hazel:
[50:04] I think there's so much about wanting to upskill them. I think it's the opportunities are not there. It's getting harder and harder to even see that so potentially go and get yourself working in a continued care model in an MGP because we know that the citizens will say you've got that but when you start speak to your buddy midwife and say oh gosh I've not been in vagina birth for a little while or can we work together on this so that I can build up my confidence because our students they definitely come out with the skills they know how to do this we we we get it into them and they reach their minimum number that they need to do by the end of their program, but they should be getting oodles of them. Like they should be getting more and more, not just reaching their bare minimum and then having to do extra shifts just to get that bare minimum.
Mel:
[50:49] So, I mean, where midwives are going to have more of an opportunity to support women who are having VBACs in more autonomous models like midwifery group practices, in private practice. So I guess if midwives are keen, they need to position themselves within facilities where their opportunities are greater.
Hazel:
[51:08] Yeah, yeah. Look at what's available out there and, and, um, Or I'll look at, you know, I don't think also then our team leaders and our managers have to go, okay, what are we doing to try and increase vaginal birth? It's not just at that individual level. It's got to be a system level. What are we doing to even create this environment? And it is very challenging. It is very difficult for our clinicians out there at the moment. So, you know, we need the bigger system changes, but we also need just the individual changes and people to go, okay, how do I upskill myself? How do I, well, it's not upskill, but how do I just know what I've got to do and how can I look at that on an individual woman level as well how can I best support her yeah
Mel:
[51:50] So that's two control confidence what were the other what's the third one that.
Hazel:
[51:54] Third one is relationship so that really goes into all the models of care so yes it's looking at the evidence on models of care and why some models of care are better or I go into whole stuff about the impact of fear-based care trustwording care like what is it that you can do are you providing that based out of fear or are you thriving that based out of trust? So when I looked at the PhD findings on this chapter, it was all this factor. It was, did women feel that they had a good relationship with a healthcare provider that was based on trust, equity, time, and support? Now, with that, continuity works really well in those, right? Because you're giving all of that. But even just one of them for time like we graphed how long women spent in appointments
Hazel:
[52:43] In all the different models of care and they spent maybe you know five to ten minutes with some doctors even in a continuity model and then it would range all the way to over an hour with privately practicing midwives now that may seem idealistic but actually if you want a good strong relationship with a woman that you're caring for and she needs to have a good one with you then time is part of that like you can't really get to know someone if you're seeing them for five to ten minutes just a few times handful of times during their pregnancy you really want to get to know them by spending longer with them now our system is a challenge for that when you've got a and actually i think it's hardest for our doctors and clinics because they get such small amount of time but therefore they should then be cognizant that they should then be referring to models where they can get a bit more time so the more continuity in the midfering models that we see the more time is allocated to appointments and the more you get to know that person because you're also seeing them differently but a part of that is also trust and equity and knowing that
Hazel:
[53:44] Different professions have different power relations with people and I think a way to disrupt that patriarchal model that we have that has got lots of different levels think of the woman is kind of like you know right down here and the midwives just a bit above and but then all the levels at the top and how that is managed in a system, a way to disrupt that is to bring the women up and bring the midwife together because that can have a more equitable
Hazel:
[54:11] Set up for all the feminist research i've done in the past so looking at that as well is it an equitable relationship are you just going there hoping that you might talk about this thing that day but they're going to talk about something else instead so you never got to talk about it
Hazel:
[54:23] And i saw that in my phd where one woman said every appointment because she was doing recording afterwards um well i didn't get to talk about my birth plan nice quick appointment i'm hoping i will next time and the spoiler is she never got the opportunity to talk about it because after every recording she would say the same thing so that healthcare provider went into her continuity with a private obstetrician went into that birth never actually knowing or potentially caring what that woman wanted it was only ever what that professional wanted yeah so that time that relationship how can you really build up that relationship-based care and you can even do that with a one-off I remember I remember this in something you said earlier and then I didn't say but in one of the workshops there was a midwife who in our same clinic did fragmented care and so she'd only ever see the woman once or twice if she was lucky and she was saying to me because we were talking about how to debrief with women and unpack their previous experience and she said you know I do do this with women she goes but I sometimes wonder should I but I do I sit there and I spend time with them and I unpack it and I help them you know think about what they can do with this next one she goes but then I'm worried because what if no one else does that with them or what if I've said the right thing I don't get to follow up with them afterwards and you know should I be doing this and this person sitting next to them who was a doula jumped up and said oh my god don't stop because please don't stop because I care for those women that see somebody like you
Hazel:
[55:51] And they're so grateful for you because nobody else bothered to ask them so please don't ever stop being that one.
Hazel:
[55:58] We had a paper that came out of BEST. It was run by our Fulbrighter, Helen. She was amazing. And we looked at what women said about all the different models of care. And in the fragmented models, one of the most important categories that came up was striking it lucky, where the woman said they met that one person that made a difference. They just did that one thing. They just said that one thing. And that midwife in my workshop was one of those striking can get lucky. Like she... Those women who were seeing her were getting the opportunity to unpack and they may never get to do that again. And she was worried whether she should be doing it. Hell, yes, she should. So how, even if you're only seeing that person once, how can you provide that trustworthy care? How can you use these things that I tell you about in the book, even just in that one appointment? Because you actually can because the woman will look back and say, I struck it lucky with her.
Mel:
[56:49] Yes, so true. You know, there's the standout midwives who don't realise they've made a difference. But once you give women information, you know, it's out of the toothpaste tube. You can't put it back in. They know now. And they go, ooh. You know what else I'm thinking is that I feel like subclinicians don't want to share the most optimal options because they're worried about increasing women's expectations.
Hazel:
[57:16] Oh, for God's sake, not expectations. I know.
Mel:
[57:18] I know I'm saying this as a total like bull in a china shop right now but it's like they think oh if I tell them all these things are possible then women start to imagine these ideal scenarios and then if it doesn't happen the women kind of have further to fall and they're going to get more disappointed because I had these really high expectations so I feel like clinicians try and keep women's expectations low almost out of a hope that they won't be so disappointed if it doesn't work or when it doesn't work because the clinician knows, gosh, this woman is up against it. She's so unlikely to get what she wants in our facility that I don't even want to set her expectation at a point where she might get that. And I think that holds a lot of clinicians back.
Hazel:
[58:06] Look, it's patriarchal bullshit. I know. Because at the end of the day, like, who are you to decide what that woman should know?
Mel:
[58:12] Yeah.
Hazel:
[58:12] Like, you should not be the person who goes, oh, I don't want to tell her about her options with me back. What if she can't get it? Or what if she's unhappy about it? That's not on you. Stop making it about you. You should be providing evidence-based care. And that translates into whatever profession you stand for. If you are not able to tell her everything out there on offer, then you are not providing your most basic need as a healthcare provider so go find somewhere else honestly like it's not for you right if you think that you must hold this back so that women don't get disappointed there's no such thing as having too high expectations in birth occasionally things go wrong and that's always going to happen doesn't matter where we are we're not robots we're humans and things happen so we can't control everything stop trying to control it let's put our level instead of right down at everyone's alive and happy well everyone's alive let's bring it up to did everyone receive respectful maternity care that is actually the expectations that people have
Hazel:
[59:16] You know, women are so smart and stop trying to have that patriarchal viewpoint that the woman that you're caring for is not smart. Stop it because we are. Women are smart. Whether you've got a degree in health or not, you are smart. We know that our bodies are not perfect. We're told that from the minute that we are young girls and we are told that our bodies are not perfect. So we know things are not always going to go the way we want, but we still deserve respectful maternity care. And if we have the bar at respectful maternity care, then there's not going to be women saying that their expectations were not met and now I've got a birth trauma because of it. That's not what birth trauma is about. Birth trauma is really about how the women lost control and didn't receive that respectful maternity care regardless of the outcome that they had.
Hazel:
[1:00:09] The women can figure that out. However, if you look at those four factors, control, confidence, active relationship and active labor, if the women felt on top of all of those that she'd had a good experience of being in control of her choices, wishes, outcomes and preferences, if she felt confident in her ability, but that's pretty hard, so was she confident in her healthcare providers? Were they confident in her? And she felt that. If she was able to have a good relationship it based on trust, equity, and support and time, and then she was able to be as active in labour as she wanted to be,
Hazel:
[1:00:42] Then she's pretty smart to figure out that if that then resulted in a repeat cesarean, it might not have been what she planned, but she understood it and she was still able to navigate that. And that's actually been a really interesting area for people to think about because a lot of people have gone, I feel okay with my cesarean and why is that? Yes well it's because you did really well on those four factors like you did everything you could you were able to go well I did it all but I couldn't get that last little bit out and there was a reason and I understand the reason and actually on the same side a woman could have a VBAC and if she had no control someone did obstetric violence on her and you know she was having to fight the whole time and she was induced and wasn't allowed to even get up and move around and she had fragmented care then she can come out feeling pretty poor about that situation So it's not always about vagina. So let's, with the expectations, scrap that. If we can set the bar at respectful return to care and we provide, we want to ensure that every woman gets that and then think about those four-factor frameworks, then we need to, we shouldn't be saying about expectations.
Hazel:
[1:01:48] It's a patriarchal view on we've got the knowledge, we want to share it with you and we don't care how you feel about it.
Mel:
[1:01:54] Well, you're right. So basically a woman's experience becomes.
Mel:
[1:02:00] Equivocal to the outcome in terms of how she feels about her birth so you know as I go back and reflect on the clients of mine who did ultimately have repeat cesarean sections a number of them have been on podcasts to talk about their experience of uterine rupture and so they talk about I was planning a home birth and I had my midwife and then we transferred to hospital and I ended up having a cesarean section which was not the thing I was planning I'd made all these other plans to have a completely different scenario and it didn't work out that way However, they're so happy with the outcome, not because of the, you know, okay, me and my baby alive, that's good, but they were treated with respect the whole time. They had options. They were aware of why things were going on. They consented and agreed to the fact that in this scenario, a cesarean section is a good idea. It's not the one I want, but it's the best option if I'm going to have the outcome that I want. It's about, so when you have a relationship with your care provider, point number three, the importance of relationship-based care, you're more likely to have respectful maternity care and therefore more likely to feel success in that scenario even if you had a repeat cesarean section.
Mel:
[1:03:15] So then, so now we've got control, confidence, relationship-based care, which is very closely linked to respectful maternity care. So then we come to the active labour point.
Mel:
[1:03:27] And what do you tell clinicians about care during active labour?
Hazel:
[1:03:32] Well, at this point, you've got to just take away the AC, not the air conditioning because I love air conditioning, but the after cesarean point, right? She's learned all this stuff in the antenatal period. You haven't got to keep throwing the rupture at her, the threat of rupture continuously. At this point, if a woman is planning a vaginal birth, then help her in every single way to be able to get that vaginal birth. And this is where I go back to where is the evidence and knowledge around how to support women to have a vaginal birth. So what about being upright? What about water birth? What about this? I look at all the evidence. And at this point, we need to take away the after cesarean part. She's just planning a vaginal birth at this point. And we need to use all of our knowledge and evidence and skills to support her at that. She shouldn't be wrapped in cotton wool she shouldn't be strapped to the bed and told she can't move just in case she explodes you don't she wants to be supported to have a pajama burst so use your skills and knowledge to help her do that and that may mean in your system and she's agreed to this to be continuously monitored guess what you do not have to be lying on a bed to even do that so I look at what does that mean what does active labor look like even if you do have monitoring on there and to move away from lazy midwifery. Lazy midwifery is putting them on the bed, strapping them to the CTG and then going to watch that on the monitor outside.
Hazel:
[1:04:49] And you know, she's got an epidural, she's happy, so it's fine. But that is so counterintuitive to actually help her have a vaginal birth at the end anyway. So why would you be doing that? That's why she's going to be feeling pretty poor about her active labour experience because she was never given that opportunity.
Hazel:
[1:05:04] Work with those midwives that are really good at using those skills. Now, that might not mean you can just go and watch home birth. It's not like, you know, it's not a ticketed event. Like, it's a very honourable place to be there. But go and speak to the midwives that are working in those areas. Go and speak to the midwives, and there will be those that work in your system and are able to support vaginal birth. Look at the birth for, and I love a quote that I actually said at your last conference, and it got so much attention, and there was, like, little images sent everywhere, which was for god's sake it's just a bath like get it in the water like it just makes no sense to me why you wouldn't i mean the long baths are not great but so many of our wonderful hospitals now and i think just in the area that i'm in in paramatta have some really beautiful birthing pools now within their within their rooms like utilize it use it get women in there get yourself confident about that because at that point she's learned all about the risk stop badgering on about you try and rupture at this point. You're looking for the signs and symptoms. That's fine. Don't keep asking her. She will tell you if she's getting them. Allow for that to happen. And now let's just focus on the active labour. We need to know those skills. We teach you those skills at university. Let's just get back into them. Stop trying to worry about what this is and keep on the bed in case she explodes. Let's encourage active labour and use our evidence and knowledge to do that.
Mel:
[1:06:26] Right. So what you're saying is once you've done all of the pre-education and she's aware of her risks and she's made her choices, that then it's our chance to step into our role as health professionals, manage our own concerns and thoughts. We don't have to share every single thing that we're thinking with the woman. You know, oh, we're really, really worried that you're going to have a uterine rupture. So we've got to put this CTG on. Oh, we're really, really worried in case you need to go to theatres. We've got to put this cannula in. Keep all of that to yourself. That's what I hear you saying. Yeah. Now it's time to tap into what the woman needs. She doesn't need to hear your fear language. I mean, I do the same thing at home and I'm caring for women who are having a VBAC. I walk in, I go, right, today, this woman's having a VBAC, which means you need to be particularly hypervigilant to this, this, this, and this. But I don't walk into her and I go, right, I've got my VBAC goggles on. I am looking for uterine rupture, for excessive bleeding, for abdominal pain, for, you know, the baby's heart rate to do one single thing that freaks me out. That's what I'm looking for. No, like you said, go in, help this woman have the best and optimal chance of a vaginal birth in the same way that you would help any woman who's come in to want to have a vaginal birth, have one. And that includes using pain relief options that don't require her to be completely numb from the waist down, active birth positioning.
Mel:
[1:07:55] One-on-one support, massage, tans, heat packs, water, showers. And the thing I'm hearing clinicians say out there as they're listening is, oh, well, that's nice. But our VBAC policy says they can't get in the bath. They have to have an IV cannula. They've got to have a CTG on. Oh, they've got to have vaginal exams regularly to make sure that they're making adequate progress. There's all of these things that can get in the way. But, again, the woman has choice in that. And I feel like if you can prepare her ahead of time, And this is where the relationship is.
Hazel:
[1:08:31] You've never met that woman and she's coming in, you know that she's telling her VBAC and you're like, oh, I want to kind of get into this. Or you're like, oh, God, that's who I've got. Like, when the first conversation, she's generally, unless she's literally pushing, which is like yay for her and a lot of VBAC people's dreams to come in and push the baby out and not have to engage. However, she's generally coming in that you can have a conversation. The first thing you should be saying is, have you got a birth plan in your bag? Have you got something there that we can talk about? Make the first thing about her the first thing is not about getting her on the bed and getting your fingers inside her as quickly as you can and making sure the cdg's on that's not what it is she's literally just been in the car and she wasn't being monitored at that point right she's walked through the corridor been on a chair she wasn't being more like chill just ask her i'm really i'm really pleased to see you i'm so excited to care for you i love coming from playing your feedback can you tell me what you want and then if she comes out and says well actually I actually don't want to have a continuous model I want to have I want to have an intermittent um institution I went on to Kirsten Small's little e-course and this is what I want to do well tick that she's already got educated by somebody who's an entire PhD and is an entire obstetrician on this so I don't need to go there and use that because I probably don't have as much knowledge as that person all right you've made your decision that's okay I just have to document it but you're not going to be burned at the stake if you write in the documentation or on emails or whatever e-notes you have to say that the woman was explained that the policy says this, the woman chose to do this. Like it's not a personal attack on you.
Hazel:
[1:10:00] They're not attacking your personal opinion. Just accept it and go, okay, that's fine. We're going to do this because if you pick up something in that intimate monitoring that is an issue,
Hazel:
[1:10:10] You're not going to go, well, I'm not going to tell anyone because, you know, she didn't have a CTG, so what do I care? You're not going to pick it up and go, all right, I can now hear that your baby's heart rate is X, Y, and Z, and this is the concerns that I've got. And my next step would be to, I'd like to put you on continuous monitoring just so we can see what's going on. I might need to report this to the person, the team leader, blah, blah, blah. Can I just check in on you? How are you feeling right now? And see what she's going on. She's like, well, obviously, you found an issue. I want to go on the monitor. That's fine. You know, like always have it. We know that women are aware things are not going to go, don't always go to a rigid plan. They definitely don't have a rigid plan to begin with. So it opens a negotiation. Just find out what it is that they want. It's for the woman. You're going to do other births. This is really one of her few. So it's just having that conversation. What does labour and birth look like? And have that conversation. Ask what's in her bag. Like I used to love being a sticky beak. I'm like, what have you got in your bag? Like tell me what's in there. Have you got some AirPods? have you got music? Have you got a special type of food? Have you got drinks? What have you got in there? This is your toolkit. I want to know what's in your toolkit and let's get it all out now and bring that bed up nice and high and put it all on there and go, oh, look at all these exciting things you're going to do and use. She's got this oil. She wants to use that. Have that conversation. If you don't, if you make it really hostile, you've never met the woman and it's all going to be on your terms, you're never going to know what's in her bag.
Mel:
[1:11:32] So basically, same thing, respectful maternity care find out what she wants and morph into the type of person who can give that to her because it's not about you it's about her.
Hazel:
[1:11:43] Absolutely absolutely and get your students in to watch this because they need to be there if you're working in a tertiary hospital you're most likely going to have students there and say this is a feedback i really want you to experience this and provide this care and be there with her the whole time feedback is awesome come on in and they will be really thrilled to be there.
Mel:
[1:12:01] And my other suggestion on this for women is when you're going into hospital, if you're in a fragmented model and you don't know who you're going to get, When you ring the hospital to let them know you're coming, say, hey, I'm planning a vaginal birth after cesarean section. Is there someone there today who would be the most ideal care provider for me? Because honestly, there are different types of midwives and the midwives who are working and the team leaders who are working know who the crunchy midwives are that would jump at the bit to help a woman have a VBAC or a breech birth or a water birth. There are a type of midwife that would be best suited to certain women. And so if you as a woman can ring in and say, I really want to get in that bath. I need a midwife who's willing to facilitate that. I'm planning a VBAC. I need somebody who is going to be on my side. It's okay to make some of your intentions known before you get there because the hospital can make some plans and go, okay, we do have that midwife here today who would desperately love to support a VBAC. Like, let's see if she's available to care for this woman who's coming in in the next 15 minutes.
Hazel:
[1:13:07] It's that whole turning it around to going on for the woman, do they deserve to be on your team? Do they deserve a spot on your team of the healthcare team, of who your support team is? And it might not be comfortable for the clinician, but then for the clinician you've got to go, do I deserve to be on her team?
Mel:
[1:13:25] Yeah.
Hazel:
[1:13:25] Do I have the knowledge I need? Do I have the right mindset I need so that I could be that striking lucky person on her team if you're not in a continuity of care model and actually even if you're in a continuity of care model sometimes you might need to go is this the right person for me yeah
Mel:
[1:13:41] And also acknowledging that it's a real privilege to have any kind of choice within maternity care unfortunately maternity care has limited resources particularly if you're living rurally there might not be the opportunity for you to pick and choose who's on your team you might get stuck with a real punk. And in that case, you need to bolster the rest of your team. So rally your partner as a sort of support person to be in your side. You could put some funds into a doula or, you know, what I call the robust friend who you are like, this person is going to come in and bat for me hard. They are, you know, they're keen. So I think in the absence of actual choice within the maternity care system, something women can do is bolster the rest of their support team so they are going in with a support network, even if you're up against challenges such as reduced choice for care provider,
Mel:
[1:14:37] a fragmented maternity care system, you know, a hospital that doesn't even have a VBAC. You've got to have something on your side and there are controllable factors in that.
Hazel:
[1:14:47] Absolutely. And that does include your peer support network as well.
Mel:
[1:14:51] Amazing. Hazel, we could talk about this all day. We've only been through a tiniest part of your book, I imagine. So your book comes out on the 1st of August. Now that people listen to this, they can purchase your book, which is called The Clinician's Guide to a Better Birth After Caesarean. And you've also got one for women. We'll be sure to put all of the details in the show notes. And if you're in on the mailing list for this podcast, you get a full resource list for this podcast so all of the links will be in there as well hazel thank you so much firstly for your passion around helping clinicians and women make vback more possible but the biggest story is we want women to have better births regardless of their previous scenarios and relationship-based care respectful maternity care i believe are the pathways
Mel:
[1:15:43] to that and that's what you're advocating for here so I don't think it's that complicated it's.
Hazel:
[1:15:48] Not we've tried to make it more complicated than it actually is
Mel:
[1:15:51] Thank you so much Hazel I'm going to encourage every midwife every clinician doula obstetrician maternity care worker who has any interest in caring for women in the way they want to be cared for to pursue knowledge in this area of better births after cesarean section and one way you can do that is through Hazel's book the clinician's guide To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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