Hospital-based Midwifery Practice

In a report of TOLAC in a hospital-based midwifery practice, the policy was to await spontaneous onset of labour, admission after active labour was established and intermittent FHR monitoring in labour. Women with more than one previous lower transverse scar or other medical or obstetrical complications were excluded. Of the 303 subjects, 84% had previous vaginal birth. The intrapartum medical transfer rate is 8.7%, similar to that of labouring women with no prior caesarean (10.4%), and VBAC rate is 98.3% with no uterine rupture. Midwifery care of women undergoing TOLAC has been reported safe and is associated with similar success rates, but studies are not big enough to determine incidence of rupture [5].

Out-of-hospital TOLAC

Several studies have looked into TOLAC in out-of-hospital midwife-led birth centres (Table 23.7) [18].

Among women with one prior caesarean, the uterine rupture and perinatal death rate is lower than the national rate for all women. Therefore, when women in medium- or high-risk categories are excluded, an out-of-hospital birthing centre is an option for TOLAC [5].

Unconventional TOLAC

On occasion, there are high-risk cases insisting on TOLAC in a setting with resources that cannot meet their risk level. An example is a 47-year-old woman in her second pregnancy contemplating TOLAC by water birth at home and the pregnancy has now gone beyond 43 weeks. This section outlines some of the principles in managing such difficult situations.

Patient-centred care is the standard in modern medicine, which treasures patient autonomy in decision making. Both professional guidelines and the law recognize the right of an adult to refuse medical intervention even if that refusal results in harm, and even death, to the patient. We must respect a woman’s decision even if we do not agree with it.

There is no legal obligation for one person to help another through their body as in pregnancy, although some ethicists argue that women have a moral duty to protect the unborn fetus within them. In English law, a fetus is not considered a legal person until it is born. A fetus has no legal rights while in utero. Our duty of care is to the pregnant women only. There is no legal duty to the unborn child [1].

For women wishing to embark on non-conventional TOLAC, we should ensure that they are fully informed to make such a decision. The decisions made by an adult concerning medical treatment are governed by valid informed consent, which requires that sufficient relevant information must be given to make a decision. Recommended information for women who consider non-conventional TOLAC should include risks and benefits of both the recommended and her non-conventional birth plan. Alternative and second opinion should also be offered. We must be content that she has capacity to make a decision and she is making a choice without duress. Her reason for her choice should be explored in the absence of family and parents. If an interpreter is needed, it should be a professional interpreter rather than a family member. Be alert to the possibility of domestic violence in women who opt for home birth. Regardless of her choice, we should continue to provide the care and support that they require in pregnancy. If complications arise from an unconventional birth plan, we will have no legal liability unless there is proven negligence on our part, e.g. failure to give relevant information. However, we must still provide care according to our professional standards. We may be held liable if our care falls below these standards. A clear birth plan made ahead of delivery disseminated to relevant staff ensures that all staff are aware of the plan once in labour, and has the legal benefit of ensuring capacity at the time the plan is made. Women in labour are considered to lack capacity with relative ease, e.g. due to pain and emotional stress of labour. Documentation must be legible, meticulous and unambiguous. There should be explicit documentation of acting contrary to medical advice [1].

Good communication skills can facilitate collaboration and compromise in proposed risky TOLAC choices, and can reduce the prospects of liability claims. A paternalistic manner is more likely to alienate a woman. Even if we do not agree with a woman’s choice, a collaborative approach aimed at maximizing fetal and maternal safety is more conducive to a good doctor–patient relationship. It helps to ensure that the woman will continue to seek help if needed rather than as a last resort [1].