Placement of Dunedin birthing unit is sound

SURPRISE! The Southern District Health Board is planning to do something sensible (in Dunedin, at least) about its primary obstetric care arrangements.

Civis commented last year on the SDHB’s decision, ‘‘justified’’ using different criteria from Ministry of Health guidelines, to close Lumsden’s birthing unit, and its incompetent delay in setting up the facilities it promised for dealing with emergency births.

But now the DHB has confirmed that the new Dunedin Hospital will have a primary birthing unit, for low risk women expected to have uncomplicated births, located beside the main maternity unit.

New Zealand custom regarding births has changed hugely over the last few generations.

Once men took their wives to the maternity hospital and then went home (or to the pub) to chew their nails until a message was received that it was all over.

Even in the 1960s, when Civis was a student living with a number of medical students, Dunedin husbands were discouraged from remaining with their wives during labour and delivery: those wanting to be present at the delivery of their child at Queen Mary Hospital had to have written permission from the attending GP and be interviewed by the QM matron to see if they were ‘‘suitable’’ to do so.

Thankfully, Civis’ first two children were delivered in Waikato Hospital’s obstetric unit, where it was assumed that the husband would be present during a straightforward labour and delivery, and by the time number three came along in Dunedin that matron had retired, and husbands were expected to support their wives through labour and delivery (though Civis knows of a doctor who had to leave his wife briefly, after her induction of labour, to deliver the baby of one of his patients).

Since then, hospital obstetric units have moved slowly towards providing comfortable, familyfriendly labour facilities, following the lead of primary birthing units, some of which even provide for labour and delivery in water.

Some people, according to SDHB chief executive Chris Fleming, have called for a completely standalone primary birthing unit, located offsite. That would be unwise.

Ideally, birth involves no medical intervention other than pain relief. But life isn’t always ideal (a visit to old cemeteries can be instructive).

Emergencies can occur, unpredictably and suddenly, even in ‘‘low risk’’ labours, threatening the life of baby, mother, or both. Responsible planning allows for that.

Delay during transfers from remote birthing units to hospital for specialist intervention is inevitable. That doesn’t justify it when it’s avoidable.

Think, for instance, about managing a prolapsed cord, where the umbilical cord slips down into the pelvis below the baby’s head, so that, as the head pushes progressively deeper into the pelvis during labour, compressing the cord, the baby’s oxygen supply is cut off.

The only way to save the baby’s life is for the midwife or obstetrician to keep their fingers in the mother’s vagina, pushing the baby’s head back, to relieve its pressure on the cord, until the baby can be delivered by Caesarean section (a GP who had to do that in QM, for a mother who’d previously had normal deliveries, for over 20 minutes, until the Caesarean section could be done, kneeling on the bed while it was eventually wheeled from the labour room to the theatre, later described his arm as remaining almost completely paralysed for some time afterwards).

Now consider the same situation arising in a birthing unit away from the hospital, and the difficulties involved in getting the mother, in labour, with a midwife in such an awkward and precarious position, to the hospital, by ambulance, for section.

That’s one of many reasons why many GP obstetricians (when they existed) were reluctant to undertake home deliveries (unpredictable postpartum haemorrhage was another).

Safe deliveries depend on careful planning for possible emergencies.

The SDHB is right to plan for Dunedin’s primary birthing unit to be separated by just a door from the main maternity unit, where emergency intervention can take place.