New Research on Planned Home VBAC in the United States: Interview with Study Author Melissa Cheyney, PhD, CPM, LDM on the Implications for Midwives

New Research on Planned Home VBAC in the United States: Interview with Study Author Melissa Cheyney, PhD, CPM, LDM on the Implications for Midwives

“Planned Home VBAC in the United States, 2004–2009: Outcomes, Maternity Care Practices, and Implications for Shared Decision Making” came out on August 26th as an e-pub ahead of print in the journal Birth: Issues in Perinatal Care. It provides a much-needed analysis of VBACs in the home setting in the United States. 

To help the birth-professional community better communicate the findings with students, clients and others considering home birth after cesarean (HBAC), Jeanette McCulloch of BirthSwell interviewed Missy Cheyney, PhD, CPM, LDM, one of the paper’s authors. The abstract of the paper, lead-authored by Kim Cox, PhD, CNM, and co-authored by Marit Bovbjerg, PhD, MS, and Lawrence M. Leeman, MD, MPH, can be found in an online-only version here

The first part of the interview is currently available in a guest blog at Science and Sensibility. In that post, which you can read here, Missy shares the findings and her recommendations for parents and policy makers. Missy shares advice specific to midwives, based on the study’s findings, here at the MANA blog. Read on to learn more.  

Jeanette: So, what advice do you have for midwives working with a family who is considering an HBAC?

Missy: I think it is important to look very closely at the mortality and uterine rupture findings presented in the paper [the study found five deaths overall in the TOLAC sample, with three deemed unrelated to the mother having had a previous cesarean]. If we look at the two instances of confirmed uterine rupture (confirmed upon cesarean section), neither of those babies died. The midwives attending these mothers were monitoring very closely during labor and caught, early on, that something was going awry, as in decreased heart tone variability and a non-progressive labor pattern. They transferred, there was a repeat cesarean, and mother and baby were discharged in excellent condition three days after their births. In the other two cases of presumed uterine rupture (no cesarean, so no confirmation), trouble was not detected until very, very late in the process, there was no time to transfer, and both babies were born at home, but could not be resuscitated. Both of those babies died. 

The MANA Stats 2.0 form had a question that asked midwives how frequently they monitored. The midwives who said their client was attempting a TOLAC did not, in many cases, also indicate on the form that they listened more frequently. Now, part of that is because the question was not asked in an ideal way, but I will say that an overall trend in our mortality case-review process is examining the degree to which some midwives are listening and whether we are listening sufficiently. I said this last year in my presentation at the MANA 2014 conference: you have got to really be on heart tones, especially if the mother has any risk factors, including a longer than average labor or a clear plateau. What we have learned from the mortality case review - which is what we did here, we case-reviewed every one of these deaths - is that midwives who were listening very diligently (so through contractions and then for 30 seconds afterwards with increasing frequency as labor intensifies), can catch early signs of decreasing variability and respond appropriately.

The other thing that's significant is that in the cases with fatal ruptures, those mothers had plateaued, so their first or second stages were stalled for a prolonged period of time, and this can be a problem. It fits with what we know from the larger body of the literature that if you have a mother that is contracting adequately and her cervix is not changing or the baby is not moving down, the strength of those contractions will cause something to open, something to move. We're hoping it will be the cervix, but if the cervix is not opening, we need to be concerned that it might be the scar. I would advise midwives attending any woman who's attempting an HBAC to be aware that a plateau itself can be a risk factor; to listen more frequently; and to have a tighter protocol around transfer. And that means acknowledging that women attempting a TOLAC are higher risk than a multiparous woman without a previously scarred uterus. I'm not saying that they are so high risk that we can never consider them for home birth. In fact, I think that some women desiring a TOLAC are excellent candidates for HBAC. But I would say, we've got to listen more carefully and engage in very individualized, shared decision-making related to the location of the placenta, length of time to the hospital, our relationships with hospital providers in our communities once we arrive, length of time between pregnancies, etc.

I think that the vast majority of midwives attending HBACs in the United States are doing these things. Yet a study like this gives us all the invaluable opportunity to stop, turn the lens inward, and think critically about how we can make our practices as safe as possible. We all know that there is no joy, no empowerment as we typically hope for our clients in an HBAC, when there is also a loss.

Jeanette: And do you recommend any additional prenatal screening?

Missy: I do. It was concerning to us (the authors) that nearly 25 percent of women in the TOLAC group did not receive an ultrasound for placental location and diagnosis of accreta prior to attempting a TOLAC at home. Given that the rate of abnormal placentation is rising, an obstetrical ultrasound should be standard of care for any woman with a prior cesarean. Also, less than 40% of the women in the TOLAC group had GDM testing. Some of this may be reflective of the difficulty in some states of acquiring lab tests and ultrasounds, and this needs to be addressed immediately. Women are going to continue to want to attempt VBACs, and HBACs more specifically. They need access to adequate prenatal screening. If we are caring for someone who already has the known risk factor of a previously scarred uterus, we want to make sure that we have normal placentation, and we want to know that she doesn't have any other comorbidities because there can be a compounding of risk, like we see in the twin VBAC case [presented in the study]. 

This study makes me think about how important it is that all maternity care providers work together to make birth as safe and empowering for families as possible, wherever we practice, and whether or not we ourselves would ever consider having or attending a home birth after cesarean.

To read the complete interview, visit our guest post at Science and Sensibility.

Author: 
Melissa Cheyney PhD, CPM, LDM
Chair, Midwives Alliance Division of Research
Jeanette McCulloch, IBCLC
Director of Communications
Blog Topics: 

Comments

Thanks for this great post and the one on Science & Sensibility. Can you speak to any recommendations for lower uterine segment assessment at term as a potential risk factor or reason to risk out/change plans from a planned HBAC. Do you recommend this also be conducted along with the GDM and placenta placement assessments? TIA.

Thank you Melissa Chaney- for looking at a subject that is so important to the families we serve. This information is especially important in California as we work to create midwifery regulations that make sense, and are evidence based!

Thank you Missy and your colleagues for your great contribution to midwifery research.
I love the questions you raise in this blogpost. Having recently attended the labor of a planned HBAC who ruptured 12 hours after transfer to the hospital, I would second your comment about the danger sign of plateau-ing in labor. I believe that a high baby is also a concerning sign. In my recent case FHTs were fine.
I am not sure about what we are to do about placental location information???? Are VBACs with anterior placentas to be not accepted as HBACs? Is the risk from an anterior placenta statistically meaningful?
And GDM and HBAC. WHat makes screening for GDM in HBACs particularly important?
My questions do not detract from my great appreciation of your work.
Thank you.

"In the other two cases of presumed uterine rupture (no cesarean, so no confirmation), trouble was not detected until very, very late in the process, there was no time to transfer, and both babies were born at home, but could not be resuscitated. Both of those babies died."

In these presumed cases of rupture, how were they not confirmed? Even if no cesarean, surely the mom needed to be transported for repair of the uterus (or hysterectomy) and it would be confirmed then?

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