PPH - would you homebirth again?

[minkymama]

Hi all,

To add context to my post, i should note that I live in New Zealand. Our maternity system is very different here what I understand the situation to be in the States - maternity care is overwhelmingly led by independent midwives, who work with hospitals, and is almost totally state funded. We have a strong principle of informed consent, meaning that you have the right to accept or refuse treatment for whatever reason you wish, and that you must be given appropriate info to make an informed decision. Having said that, the norm here is still medicalised hospital birth, and our hospital stats are still way too high for interventions and c-sections. i have heard of and witnessed births that were mismanaged by the hospital and resulted in the 'cascade of interventions.'

I'm struggling to come to terms with my birth choices. This is my 4th pregnancy, i have had one live birth. The rest have been miscarriages - from when I was 18 to now (I'm 34), so spread over a long period. The reasons for those aren't my issue here - my issue is what happens after.

Every pregnancy, including the birth of my DD, ends in massive haemorrhaging. DD's birth was the worst - I lost 2000mls of blood and needed 4 bags transfused. I always need surgery after for retained placenta. No-one seems to know why this is - I've had opinions ranging from atony to accreta. I suspect I have multi-lobed placentas. I'm going to request an MRI when I see a specialist at 30 weeks (I'm 20 weeks now), to check out the placenta.

I birthed DD at home and the labour went smoothly - it was longish (50 hours), but I got her out with no complications. I had a healthy pregnancy. 15 minutes after the placenta was born, I had a pph - placenta seemed complete, but then i lost 1500ml in one big go. We transferred to hospital (5 mins away), and I was monitored for 5 hours until staff decided surgery and transfusion was needed. They removed retained placenta in the surgery and after that and the transfusion I was fine.

So, my question - should i birth at home this time? My midwife (homebirth midwife, same as last time) would prefer me to birth in hospital but says the choice is mine. The 2 OBs I have spoken to (in the context of my miscarriage between my pregnancy with DD and this pregnancy, so wasn't really a formal opinion) say hospital is a must. The thing is, no one has described the risks to me to my satisfaction. I was fine with how my last birth went. The PPH will happen no matter where I am, so why not birth at home? Plus the fact that they monitored me for 5 hours at hospital - while I lost a lot of blood over those hours, it wasn't exactly urgent.

The clearest explanation I've had so far is that the biggest risk is me bleeding out so fast that they won't be able to get a line in for blood. We've moved since DD's birth and are now a minimum 40 minutes from hospital so I guess that could be a concern. I am less comfortable with homebirthing now than i was before DD, because of my experience of pph. I don't want to bleed to death, but no-one can give me the odds on how likely that is.

I would be happy to birth in hospital if I could have a guarantee that it would be just me, DH and the midwife, and that the hospital staff would leave us alone. My main worry is that I am giving up too easily on homebirth, and putting myself into the hands of a system where, because I am labelled as high risk, I will have to fight against unnecessary monitoring, interventions and scare tactics.

On the other hand, i don't want to bleed to death at home, but I'm not sure how likely that is. Is the risk any higher than it was with my birth with DD, where my m/c history was known but not judged to be a risk? Is it any higher than it would be for a pregnant women with no history of complications?

Sorry for the long post, but I'm struggling to get my head around this. What would you do?

[AAK]

Your midwife that you had before said she would choose a hospital but would support you either way, right? Would she also be the mw that attended you at the hospital? If the answer is yes, then I would expect her to realistically answer the questions/concerns you have about hospital staff. If it sounds like you can "lock the door" so to speak--then I would go for the hospital. That is just me though. And the main reason is because of your distance.

Also, ask your midwife what she carries with her for pph. How fast it works, etc. Was it used last time, or did you just move quickly to the hospital?

Amy

[bicyclingbethany]

I guess you just have to ask yourself- Is it worth the risk? 2L of blood is a lot. That's nearly 1/2 your blood volume (when you're not pregnant).
Also, why are you hemorrhaging every time? Is it more likely to be worse in the future? Are you at a higher risk for placental abruption? etc...

I would go with the hospital, especially if that's what the MW and OB recommend.
Birth is powerful and amazing no matter where it happens.

[Happiestever]

If I were you I would just go into the hospital right before you deliver. Just labor outside if the weather allows. If you feel like you will have the same birth and will require transfusions and help with the placenta then you would be in the right place most likely. You can definitely have a birth with just the people you want around, you have may to scream a bit, but they'll get the point. That's just me though. I felt like my bleeding has gotten worse each time, so that's not a point in the right direction for me.

[minkymama]

Bicyclingbethany, Happiestever, AAK, thankyou all for your replies. Just posting in Mothering Commune helps as I feel I am getting feedback from people who are on the same page - NZ is a fairly conservative country (not that the States isn't) - but I feel there is a greater degree of awareness of alternatives amongst Americans than in NZ. You guys have confirmed my feeling that hospital is the safest place - I needed to test that feeling here

AAK - yes, my midwife would attend me at the hospital - and I would be under her care unless a complication arose that required an OB. She is honest about the chances that hospital staff will try and intervene (reasonably high), and that we may have to argue to have our views prevail. With DD, my midwife and the backup midwife set up a mobile drip for something - syntocin/oxytocin, whatever it is they use to encourage contracting - so they have all that with them for a homebirth, but the bleeding was extreme (and the cause was retained placenta, so not sure if those drugs even help?). It couldn't be managed at home. The OBGYN who saw me the next day was like 'Do you know how close you came to dying?' I treated the whole thing as an exciting adventure at the time, but last year I ordered my notes and saw that the midwives and paramedics were unable to find my bloodpressure after the first big gush. That's when I started to question where to birth!

I hadn't thought about staying outside (you mean outside on the hospital grounds?) until it's time to go in. It would work well if our hospital had grounds, but its an urban hospital on a busy inner city block. I have friends who live 5 mins away so might see if we could hang with them if its not the middle of the night.

[loveneverfails]

With that high a blood loss, I would choose a hospital birth for this pregnancy and reserve the right to choose a home birth if you have another child down the line. Right now, you don't know if the PPH was a freak occurance or if it's something likely to recur, and 2000cc blood loss is not 1000 or even 1200.

1500 or over would be the tipping point for me, and it's obvious you had some serious complications associated with this bleed. Good luck as you figure out what is best for you!

And I'm saying this as someone who has had PPH and chooses home birth. With some PPH, I think homebirth is still a reasonable choice, but with blood loss that high I would personally not be comfortable with it.

[blessedwithboys]

i would deliver in hospital, but i would labor at home. if your previous labor was 50 hours, i would venture to guess you will have plenty of time to make the 40 mis drive. can you get a hotel room close to the hospital to labor the last few hours? can you maybe even deliver there, in the security of knowing you are just 5 mins away like you were last time?

if you choose to birth at home, 40 mins from hospital, is there an option to be air-lifted should you need to go in pp?

[*MamaJen*]

I think if I were in your situation, the deal breaker for me would be the 40 minute drive to the hospital. If I were still 5 minutes away I might possibly consider it (though with blood loss that high I think I'd still be leaning towards hospital birth, especially if it could be midwife attended), but not 40 minutes.
I think homebirth is safer than hospital birth for low risk women, with a trained midwife, and with fast transfer procedures in place in case of emergency. I would say that you don't hit two out of three of those in your current situation.
Do you feel like your midwife would advocate for you during a hospital delivery to help avoid the cascade of interventions?

[alton]

It sounds to me like you need to have a strong advocate that you can depend on, so that if you do go into hospital you can switch off and focus on labour, and let someone else fight the battles if they need fighting. The last thing you need is to be going into a "war zone" when you should be feeling relaxed and safe.
Do you know anyone who would be a good advocate for you - obviously your midwife will to an extent, but maybe (maybe not) you need more than just her in your corner?
If there was a hotel near the hospital, that could be an option for labour - especially if the rooms come with bathtubs!
Is this hospital your only option? I know it is the closest, but even if you found one a bit further away that seemed a better "fit" for you, it might be worth the extra distance.

Basically I'm just trying to suggest a few of the ways that you can create a safe labour space for yourself in hospital. When you have a homebirth, creating a nest to labour in is straight-forward. You need to create that nest for yourself in hospital too, and you sort of have to be crafty to do it, but it can be done!

[minkymama]

The hospital has a helipad, but I'm not sure how a helicopter would collect me from home - we're on a steep, winding hill with nowhere to land. A hotel is definately an option, and one I've been considering. If we still lived in our old apartment, which was 5 mins drive from the hospital, I'd do the bulk of my labour there and then transfer for delivery. I'm not sure about labouring here at home in case of a quick birth and then a pph. There is only one highway into town and if the labor/birth happened at rush hour, I don't see how an ambulance could get through the gridlock, even with lights and siren - there'd be nowhere for the traffic to move to.

You guys are right - the distance from hospital is a dealbreaker. My midwife will be a strong advocate in hospital. They have a dumb policy that every mother who comes in has to have continuous electronic monitoring for the first 20 minutes after admission, to check for fetal distress. In the second stage of my labor with DD, my midwife checked her every 5 minutes with a doppler and she was so unintrusive - that's the kind of thing I'll be arguing for.

[minkymama]

Hi Alton - I x-posted with you. The nest is my issue with hospital. I can't imagine the state I would have been in if I'd had to transfer with DD in labor. My state of mind during labor is impossible to put into words. Plus I was feral - I was naked and dripping with amniotic fluid, and it didn't matter cos I was at home!

There is a birth centre up the road but they won't admit me because of my risks. There is a second tier hospital an hour away (the hospital I'm supposed to go to is third tier - highest facilities, ie it has a neonatal unit and full range of surgical theatres). All 3 facilities (the second and third tier hospitals and the birth centre) are run by the same government management, so they all have the same policies.

I feel like I do need more than my midwife in my corner, even though she is great. She's been bringing a student to our appointments who I really connect with, so I'll sound her out.

The maternity staff at the 3rd tier hospital were lovely to me when I was recivering from labor, and during my miscarriage. I'm just worried they'll be difficult, policy-wise, when I'm in labor. Plus its a teaching hospital and they really push the students on you.

Out of my friends, I'm the only homebirther, so I don't think I could call on one of them. We won't even discuss my family here!

NZ doesn't have a doula industry. Might be a need in the market here!

[JennTheMomma]

I'd deliver in the hosital if I were in your situation.

[tireesix]

Why are you suffering PPH?

Have you been checked for any possible health problems that might be causing it?

[*Jade*]

I feel your pain. I'm coming up to my first birth, and my midwife (and the OB team at Akl hospital) have basically put their foot down and said I need to be in hospital in case of PPH.

I hope you can find a solution you feel good about. I know it's taking me a while to come to grips with the idea that I'll be in hospital, and not where I've always pictured myself.

[UmmAbduRahman]

If it were me I'd choose the hospital, especially if I could get midwifery care there.

[at_the_hip]

I have had 2 pph (middle two births) but no retained placenta and no need of transfusion. With the history you have had and especially the severity of the pph, I would in your situation deliver in-hospital with my midwife. I am another who is comfortable homebirthing (this will be my third hb), but we were able to prevent it with #4 and are adopting the same preventable measures. FWIW in my situation, my mw at home handled #3's pph better than the hospital did with #2.

Oh and in case you are interested - our preventative measures consisted of Floradix during pg, Mother's Cordial herbal blend from 36 weeks, and IV/oxytocin with active management at birth. Success, with less than average bleeding and an amazing recovery.

[minkymama]

at the hip, I AM interested! I may copy your method, anything that reduces the bleeding will increase the time I get with the new babe; DD and I had 15 mins together and were then seperated for 4 hours or so.

No-one can tell me why the pph happens. I'm seeing a specialist at 30 weeks, so will try and interest them in exploring why.

Jade - why are they insisting? Do you have particular risk factors, or are they using the possibility that pph may occur to stop you homebirthing? PPH is always a possibility but is more likely in hospital as a result of being pestered by staff during and after labor. Also the severity differs - any blood loss above 300ml(?) is classified as pph, but a small loss can be managed at home. What happened to me was relatively rare, and I was still ok.

[Paige, CPM]

Hi there,

For me I think the issue is distance from the hospital. Since your first term? (I am guessing) birth was pretty long, this may have contributed to uterine atony and hemmorhage. It may be different next time, especially if your labor is faster. I gather you have been tested for blood disorders because of your 3 miscarriges...like Factor V Ledden (sp?), for example?

If you have been fully tested and have no known blood clotting issues I think hb is a reasonable choice when the hospital is close. 40 min away would make me nervous with your history though.

So, you could also have a heplock placed in your arm for the birth and iv ready to go in case. You can also have your midwife be proactive by giving you a shot of pitocin right after the baby is born, or cytotech up the bum to help with uterine tone. Alerting ems and your closest hospital when you are in labor and may need their help might also be a good way to go, so everyone is really ready and preped should you need them.

Still with these precautions 40 min away with a history still makes me nervous...talk to your midwife about all of these things and more, I would say.

Also, have you considered going somewhere closer to the hospital for your birth, like a friends or relitives house or renting a flat? Some people give birth at hotels. Perhaps you could bribe friends or relitives to leave thier homes so you can have privacy for your birth?

Some people have also been proactive with their hospitals and have set up meetings with the head nurse / obs to discuss wishes and privacy to help make the atmosphere more of what they were looking for...like addressing things ahead of time instead of during labor (impossible!).

Just some thoughts...good luck with your decisions and keep us posted!

[minkymama]

Thanks Paige...what a beautiful pic of you and your LO. I haven't been tested for anything - I don't know if this is a New Zealand thing, but all the medical professionals I've come into contact with about this issue seem to have the attitude of "Meh, stuff happens, who can say why?' I'm seeing an OBGYN at 30 weeks so maybe there'll be some answers/testing then. Because its publically funded I can't pick my OBGYN (unless I paid, which would be thousands), so it will be luck of the draw!

My midwife wants me to make a care plan with the OBGYN, so that's the place I'll seek to address my need for privacy and non-interference - I like the idea of meeting with the delivery ward staff, it may dispel a lot of my worries and that in itself will greatly help my labor. My fear, apart from getting messed with, is that I'll tense up in hospital and my labor will stop. And that will lead to messing!

I read Ina May's latest book not long ago and I want to specify that I want to try methods like the hip press and clitoral stimulation if labor does slow, so hopefully my care plan will look so mad that they'll be scared to come near my room!

We could check into a hotel if its before 10pm, when most receptions close. There isn't anyone close we could really stay with, but we could look at renting a short-stay apartment.

I will be registered with the hospital before the birth, and they will have a full copy of my notes. My midwife would like a heplock, but I find them wildly uncomfortable and it would interfere with my labor. I would probably rip it out my arm during transition!

[*Jade*]

Originally Posted by minkymama

Jade - why are they insisting? Do you have particular risk factors, or are they using the possibility that pph may occur to stop you homebirthing? PPH is always a possibility but is more likely in hospital as a result of being pestered by staff during and after labor. Also the severity differs - any blood loss above 300ml(?) is classified as pph, but a small loss can be managed at home. What happened to me was relatively rare, and I was still ok.

Elevated BMI They also think my pelvis will be too small since I'm short. At this point I'm ok with a hospital birth, and I've got a good midwife who is all about seeing what I can actually do in labour, rather than looking at the risk factors. I'm hoping to blow them all away