Q. Hi I would really like either a home birth or to a least be able to go to the midwife led unit attached to one of our local hospitals. However I am regularly being monitored by the obstetrician as I had ashermans syndrome and they have said that i will be having a hospital birth. I am 30 weeks pregnant now and so far no complications. I know they are being extra cautious (which is good) but are compromises made in situations like mine where the pregnant woman aspires to a mpre natural environment to give birth in but is considered `high risk`

A. It can be frustrating, not to mention upsetting, when you've set your heart on something, only to find that circumstances beyond your control look set to impede things. This seems to be the case for you, where you would like a more home-like environment for your baby's birth, but are being advised by your obstetrician to have a hospital birth because of the potential risk of complications. While you may have heard that ‘hospitalised' births are ‘less good' than births in midwife led centres or home births, this is not necessarily the case. Obstetricians and midwives work together with you and your partner to try to help you have the same choices for labour that are important to you.

Women's informed choice in pregnancy and birth is a central aspect of modern maternity services and, as such, midwives and obstetricians should always aim to support and facilitate women's preferences. However, where your obstetrician feels that these choices might compromise you and/or your baby's health and safety, they have a professional duty to advise you accordingly. This can mean that while they will always take into account your preferences, these need to be balanced with what is considered the safest option for you and your baby. In this case, they are advocating that you give birth in hospital where there is immediate access to medical support and equipment, should these be needed.

I am pleased to hear that your pregnancy is going well and that at 30 weeks' there haven't been any complications. However, your obstetrician will want to continue to monitor you and your baby regularly throughout the remainder of your pregnancy, to ensure that your baby is growing well and the pregnancy is progressing smoothly.
As you'll be aware, Asherman's syndrome - also known as ‘uterine adhesions' - is a condition that is characterised by the presence of scar tissue called adhesions inside the womb (uterine cavity). Scar tissue that binds two parts of your body tissue together when they should be separate from each other can cause abnormalities that affect the functions of the uterus and sometimes other surrounding tissues. This scar tissue develops when the body's repair mechanisms respond to any tissue disturbance because of surgery, infection and/or trauma. There may be more than one reason why Asherman's syndrome develops; these include having a caesarean section or other type of surgery on your womb (uterus), undergoing D&C (dilatation and curettage) for the removal of a retained placenta (afterbirth), or having had a miscarriage.
The concern where someone has Asherman's syndrome is that the presence of adhesions inside your uterus can affect the way the placenta positions and imbeds itself, particularly how deeply it beds into the wall of your uterus. As you are now 30 weeks into your pregnancy, your doctors should know the position of the placenta, but they cannot be fully aware of other factors related to this condition until you either go into labour or have given birth; this is when the placenta should separate from the uterus.
Your obstetrician's primary concern will relate to whether your condition has damaged, or scarred the lining of your uterus (endometrium) to the extent that it has affected how your placenta has attached itself to your uterine wall. Asherman's syndrome is associated with a greater risk of the placenta imbedding itself abnormally deep into the muscle of the uterine walls (myometrium); this condition is called ‘placenta accreta'. It is notoriously difficult to diagnose during pregnancy and problems only arise when the time comes to deliver the placenta.

Whereas, the placenta usually peels away from the uterine wall quite easily, in placenta accreta it is so deeply embedded into the uterine muscle that there can be a significant risk of haemorrhage during its removal. This often means that removal of the placenta needs to be undertaken in an operating theatre to ensure that the placenta has been completely removed and the bleeding stopped. This is one reason why your obstetrician is recommending that you have a hospital birth. As your pregnancy progresses, this will also put greater stress on the uterus, and everyone will be taking great care of you to ensure that any risk of preterm labour is avoided. They will also ensure they discuss with you a plan of care for your labour, which will offer both you and you baby the least risk of harm.

As I mentioned earlier, you have a right to make an informed choice. This choice, however, needs to be based on sufficient and appropriate information that you understand and are able to use in weighing up the risks, benefits and alternatives associated with the various options. It is therefore important that you talk to your obstetrician and midwife, who will be able to explain why they are recommending a hospital birth. They should also be more than happy to talk through any concerns that you might have and it may be possible to reach a compromise. Perhaps, when you go into hospital for the birth, the birthing room could be made less ‘medical', eg the delivery bed could be pushed into a corner, so that it doesn't dominate the room and you could have access to floor mats, a birthing ball, rocking chair etc. You could also request to have the room lights dimmed to give a more natural and gentle ambience to the birth environment.

It may also be helpful to contact one of the Supervisor of Midwives at the hospital. They can talk through your preferences, and alongside your midwife and obstetrician, help you to develop a birth plan that reflects your preferences, while also safeguarding you and your baby's health and well-being. The Nursing and Midwifery Council (NMC) have produced a leaflet that might be helpful to you:
Support for Parents: How supervision and supervisors of midwives can help you. Your midwife should be able to give you a copy; alternatively, you can view the leaflet online at: http://www.nmc-uk.org/aDisplayDocument.aspx?DocumentID=6227.

Further information about Asherman's syndrome is available from their support group at: www.ashermans.org

I hope this information is helpful to you.
My very best wishes for your pregnancy and birth

Best regards

Vicky