Help me understand risks and solutions of homebirth

[Path2Felicity]

I had a hospital birth with my first baby, and it turned out to be an awful experience.

I resent the fear surrounding birth in this country, and I have read most of the birthing books.  However, when thinking about the “other” side, I continuously read things about how an emergency can be imminent and immediate transfer can not get a patient to a doctor in time.

So, what are the events in a birth that are deemed a sudden emergency?  What should a qualified midwife do to control for these?  Can we start a list?

I can begin:

1) Placenta pervia

2) Prolapsed cord

What else?  How would an experienced midwife handle these situations?

Am I looking at things wrong?  Should I not approach it like this?

[msmiranda]

This is exactly the way I look at it and I've been compiling a list in my head.

Placenta previa would almost certainly be diagnosed before labor (and it is an absolute indication for a c-section), so I don't think that would be on the list as a sudden emergency.

1. Cord prolapse.  solution: EMS called, get on hands and knees with butt in the air, midwife or someone holds baby's head up manually to keep pressure off the cord, you ride in the ambulance that way and emergency section at the hospital.

2.  Placental abruption.  solution: emergency transport to hospital, emergency c-section.

3.  Shoulder dystocia.  solution: Gaskin maneuver, sometimes breaking baby's clavicle to get her/him out.  This one is time-sensitive enough that it has to be handled at home, and midwives are trained to handle it.

4.  Head entrapment (breech).

5.  Uterine rupture.  solution: emergency transport to hospital, emergency c-section and possible hysterectomy for mother.

6.  Baby not breathing after birth.  (I have heard a story of this happening for no apparent reason and the baby died).

7.  Placenta accreta/increta/percreta. 

8.  Postpartum hemorrhage.  solutions: pitocin shot, shepherd's purse to manage at home; if bad enough, emergency transport to hospital and pitocin IV and possible blood transfusion.

That's just a partial list from my admittedly limited knowledge.  I'm sure a midwife or midwifery student could add to the list.

[GoBecGo]

Originally Posted by msmiranda 

This is exactly the way I look at it and I've been compiling a list in my head.

Placenta previa would almost certainly be diagnosed before labor (and it is an absolute indication for a c-section), so I don't think that would be on the list as a sudden emergency.

1. Cord prolapse.  solution: EMS called, get on hands and knees with butt in the air, midwife or someone holds baby's head up manually to keep pressure off the cord, you ride in the ambulance that way and emergency section at the hospital.

2.  Placental abruption.  solution: emergency transport to hospital, emergency c-section.

3.  Shoulder dystocia.  solution: Gaskin maneuver, sometimes breaking baby's clavicle to get her/him out.  This one is time-sensitive enough that it has to be handled at home, and midwives are trained to handle it.

4.  Head entrapment (breech). i have a friend whose baby died of this.  It is much more common in mishandled breech births (where a careprovider manipulating, pulling on or sometimes even just touching the baby which causes the baby to unflex its head), so a planned breech HB will very very rarely result in this.  For an unplanned breech the reaction will vary from MW to MW - ask ahead of time.  If the MW is happy and comfortable delivering breeches she will most likely just get you into a good position with an open pelvis and NOT touch the baby until it is born.  A less comfortable MW or a mama that wants it can call an ambulance before the baby is emerging (as soon as the breech is visible).

5.  Uterine rupture.  solution: emergency transport to hospital, emergency c-section and possible hysterectomy for mother.

6.  Baby not breathing after birth.  (I have heard a story of this happening for no apparent reason and the baby died).  My MW was fully trained in neonatal resus and had all the requisite equipment with her.  My DD1 did need suction and oxygen to get going well and it was done very smoothly - baby was taken to window to observe skin tone in good light as they suctioned and gave some oxygen with mask, once she was beginning to stir she was put onto my chest to help her regulate her systems and i held the oxygen tube (with the mask off) under her face so it was blowing against her nose and mouth.  Her apgars were 9, 7 and 10, i think the premature cutting of her cord was what caused the dip.

7.  Placenta accreta/increta/percreta. They would call EMS and transfer for PPH/non-delivered placenta and it would be dx and dealt with in the hospital.

8.  Postpartum hemorrhage.  solutions: pitocin shot, shepherd's purse to manage at home; if bad enough, emergency transport to hospital and pitocin IV and possible blood transfusion.

That's just a partial list from my admittedly limited knowledge.  I'm sure a midwife or midwifery student could add to the list.

I'm not a midwife.  I had the same questions and did the same research when i was expecting #1.  I filled out a little with bolded text.

Something of what comforted me was finding out how common these things actually are, and also what would happen if i was already in the hospital.  At my local hospital the average time taken from dx of need to birth of an emergent c-section is 45mins.  That is not to say that some babies don't need and get faster treatment, but that the majority of c-sections those doctors are doing, the most COMMON reasons for csections, were not at all deadly situations.  If you have a MW who can deliver in hospital then it's likely they can be setting up theatre/getting team assembled while you transfer.

[Aliy]

let me get back to you on this.. I'm actually planning on having a discussion with my midwife today about the risks and such.

yes there are some risks asscoiated with having a homebirth but there are also a number of risks asscoiated with being in the hospital. i to am planning my first homebirth after having two realivley easy hospital births.

A properly equipped midwife will have on hand the nesscary tools for many things that a hopsital will have for emergency. In some more remote hospitals they will have pretty much what they would have.

[mdnaturalmama]

I have nothing to add, but wanted to say as someone who's also planning my first HB I am loving this thread. I admittedly don't know many of the problem/solution scenarios yet so this is great for me. Thank you!  =)

[Mama Metis]

I just wanted to add that the research shows that a key element in the safety of homebirth is that the midwife is well integrated into the health system. So I would add in several of the emergencies listed above, that the midwife would call ahead to the hospital to have the OR prepped and the surgeon present. This cuts the delay significantly and is a key condition for me choosing homebirth. In my case, this means I chose a homebirth CNM who collaborates with docs/hospitals to make this link smooth. The awesome homebirth study results in Canada and the Netherlands have a lot to do with how well midwives are integrated into the system overall. And it may also be part of the reason that US homebirth stats look pretty terrible by comparison, since many midwives lack this connection and have trouble facilitating a smooth transfer.

[Singfourever@yahoo]

Originally Posted by Mama Metis 

I just wanted to add that the research shows that a key element in the safety of homebirth is that the midwife is well integrated into the health system. So I would add in several of the emergencies listed above, that the midwife would call ahead to the hospital to have the OR prepped and the surgeon present. This cuts the delay significantly and is a key condition for me choosing homebirth. In my case, this means I chose a homebirth CNM who collaborates with docs/hospitals to make this link smooth. The awesome homebirth study results in Canada and the Netherlands have a lot to do with how well midwives are integrated into the system overall. And it may also be part of the reason that US homebirth stats look pretty terrible by comparison, since many midwives lack this connection and have trouble facilitating a smooth transfer.

What do you do in my position?  There are no doctor/midwife relationships where I live.  A doctor won't even see me during pregnancy because I'm planning a homebirth.  There is no support whatsoever.  All the CNMs deliver in hospital only.  I know because I called every one for insurance purposes.  I look for a midwife I trust implicitly and assume that upon calling the hospital in an emergency, they listen and believe what we tell them.

[MeepyCat]

Singfourever, if it were me, I'd look for a doctor or a CNM that I could trust to work with in the hospital.    The more I've looked at how long it takes to transfer, the more I am convinced that situations like placental abruption just can not end well if they occur at home.  My experience is that I developed good relationships with my HCPs during pregnancy, and that those relationships made it easier for me to navigate the hospital system successfully, *even when the HCPs I'd dealt with during pregnancy weren't present.* 

The less contact you have with the hospital system before labor begins, the fewer options you wind up having if you have to go there in an emergency.  Before labor, you can say what you want, and why, and find out what the policies are, and how and where they can be flexed.  When you come in laboring, and they have to take you on with no prior knowledge, they have to assume the worst on pretty much every front, and you have much less room to maneuver.

[mom2clairenlily]

Originally Posted by MeepyCat  The more I've looked at how long it takes to transfer, the more I am convinced that situations like placental abruption just can not end well if they occur at home.

I fully agree with this statement.  It seems that in a lot of discussions on homebirth complications the answer "transfer" is inadequate.  When you figure in the time it takes to make the call, an ambulance to arrive, transport time, plus the time to get into the hospital, see the appropriate provider, get their assessment then treatment can be a substantial amount of time.  Whereas if you were in a hospital and had, for instance, a postpartum hemorrhage, they have drugs, blood, an OR, anesthesia, etc either on hand or on call, the response time is substantially shorter.

I think it is a good conversation to have and to fully understand the risk involved.  I think everyone should be able to choose if they have a homebirth or not, but I think that the risks have to be clearly stated and accepted by the mother before proceeding.  Just saying homebirth is "safe" is inadequate, and really does not provide informed consent as is advocated for so strongly on these boards.

Just my two cents :-)

[Path2Felicity]

Okay, so, I will  ask my questions regarding each of the complications brought up.  I would like to keep this thread as bias-free as possible- I really hope to get some answers and not speculation and commentary.

1. Cord prolapse.  solution: EMS called, get on hands and knees with butt in the air, midwife or someone holds baby's head up manually to keep pressure off the cord, you ride in the ambulance that way and emergency section at the hospital.

1- How effective is it to get on hands and knees with the butt in the air?  Does that actually help stop the cord from coming out? 

2- How quickly does a transport to the hospital need to take place in order for a safe delivery?

3- What are the signs of cord prolapse?  At what point should a good midwife start to think of transport?

2.  Placental abruption.  solution: emergency transport to hospital, emergency c-section.

1- What are the signs of a placental abruption?

2- When would a trained midwife know when to transport?

3- How quickly does a transport need to take place in order for a safe outcome?  How quickly does it happen in a hospital?

3.  Shoulder dystocia.  solution: Gaskin maneuver, sometimes breaking baby's clavicle to get her/him out.  This one is time-sensitive enough that it has to be handled at home, and midwives are trained to handle it.

1- When I read Ina May Gaskin's book, she made it seem like her method was effective the vast, vast majority of the time.  Is this true?

2- How tragic are the effects?

3- How often does this occur and how is it handled in the hospital?

4.  Head entrapment (breech). i have a friend whose baby died of this.  It is much more common in mishandled breech births (where a careprovider manipulating, pulling on or sometimes even just touching the baby which causes the baby to unflex its head), so a planned breech HB will very very rarely result in this.  For an unplanned breech the reaction will vary from MW to MW - ask ahead of time.  If the MW is happy and comfortable delivering breeches she will most likely just get you into a good position with an open pelvis and NOT touch the baby until it is born.  A less comfortable MW or a mama that wants it can call an ambulance before the baby is emerging (as soon as the breech is visible).

1- Do homebirth midwives deal well with head entrapment?

2- If a woman doesn't know her baby is breech and her midwife doesn't want to handle it, can she transport?

3- How often does head entrapment occur?

5.  Uterine rupture.  solution: emergency transport to hospital, emergency c-section and possible hysterectomy for mother.

1- Uterine rupture is more common in vbac's correct?  How often does it happen in a woman with no previous cesarean?

2- What are the signs of uterine rupture?

3- At what point should a transport to the hospital take place?

4- How quickly does a transport need to take place for safe outcomes?

6.  Baby not breathing after birth.  (I have heard a story of this happening for no apparent reason and the baby died).  My MW was fully trained in neonatal resus and had all the requisite equipment with her.  My DD1 did need suction and oxygen to get going well and it was done very smoothly - baby was taken to window to observe skin tone in good light as they suctioned and gave some oxygen with mask, once she was beginning to stir she was put onto my chest to help her regulate her systems and i held the oxygen tube (with the mask off) under her face so it was blowing against her nose and mouth.  Her apgars were 9, 7 and 10, i think the premature cutting of her cord was what caused the dip.

1- From what I understand, it is pretty common for midwives to be trained to resuscitate babies if they are not breathing, correct?

2- How often are midwives not able to help a baby to start breathing again?  When is a transport to the hospital required?

3- I am assuming a quick transport would be needed.  Is this something generally done at home before the transport?

4- What are the reasons for a baby not breathing?  Can this be detected before hand?

7.  Placenta accreta/increta/percreta. They would call EMS and transfer for PPH/non-delivered placenta and it would be dx and dealt with in the hospital.

1- I am not familiar with placenta accreta/increta/percreta.  Could someone explain what this is and why it's so serious?

2- How urgent is it?  When does this occur in the labor?

3- How quickly is a transport needed for a safe outcome?

4- What are the outcomes associated with this?

5- Are there any signs of this happening?

8.  Postpartum hemorrhage.  solutions: pitocin shot, shepherd's purse to manage at home; if bad enough, emergency transport to hospital and pitocin IV and possible blood transfusion.

1- How often does this happen?  I feel like it happens pretty often.

2- Are homebirth midwives generally trained in handling this?

3- How quickly does a woman need to be transported to the hospital for a safe outcome?

4- Are there signs that a mother could possibly begin to hemorrhage? 

Again- let's try to be as objective as possible so we can get some real answers and so women can objectively weigh the risks of homebirth against the risks of hospital birth.

I appreciate everyone's knowledge and help in navigating this!

[CookAMH]

I'm glad for this thread and my husband and I are currently weighing the option to HBAC.  Will be following this.

[mwherbs]

So from recent studies the average risk of abruption is less than 1%, with term abruption being around .3% or less and with preterm abruption being a much higher risk of about 5%.  


Here is a quote from a study published in Sept 2010,

"During the study period there were 185,476 deliveries, of which 0.7% (1365) occurred in patients with placental abruption. The incidence of placental abruption increased between the years 1998 to 2006 from 0.6 to 0.8%. Placental abruption was more common at earlier gestational age. The following conditions were significantly associated with placental abruption, using a multivariable analysis with backward elimination: hypertensive disorders, prior cesarean section, maternal age, and gestational age." 
There is s pretty high mortality rate associated with abruption since the studies are done for in hospital births being there is not necessarily preventative .. Another study published in08

"Preterm placental abruption is an unpredictable severe complication associated with significant perinatal morbidity and mortality. Factors found to be independently associated with placental abruption were grandmultiparity, severe pregnancy-induced hypertension, malpresentation, earlier gestational age and a history of second-trimester vaginal bleeding."
 
And another older article" Abruption of the placenta at term was found to be significantly associated with PIH, non-vertex presentation, IUGR, hydramnios and advanced maternal age."

There is a smaller subset of women with hyperthyroidism that have increased risk of having an abruption. The numbers are not good even in hospital, but it is a relatively rare emergent event.

Prolapse cord is also a fairly rare risk, that is not necessarily improved by being in the hospital when it happens , the CPM study one of the home birth deaths was an appropriate transfer for unusual heart tones, as a routine procedure the nurse AROM and the cord prolapsed , so this prolapse occurred in the hospital and they did not save the baby. Again the majority of cord prolapsed occur in preterm births, presentation other than vertex, unengaged head at time of rupture of membranes , no cord wraps, IUGR babies ...

As for having a medical back up, may or may not help, depends on your area and who is on call and where your provider is when you transfer in. Larger hospitals have staff on 24 hrs and so will have a team ready, calling ahead and giving report to the head ob nurse or actually getting the on call doc on the line and talking to him/her can expidite transfer . Smaller hospitals can be similar and possibly more crucial to call ahead and get the docs on the way. Emergency transfer can happen quickly .

Things like placenta Previa are usually detected before term , signaled by an early bleed, so many women have ultrasounds now this is rarely a surprise again increased risk for previous csection.
After 2 unmedicated hospital births, in recovery from those births the first book I read was obstetric emergencies .... So I understand wanting to know This stuff, I recommend doing some research via pub med and emed sites as well as doing searches here .

[womenswisdom]

Path2Felicity - All the questions you are asking are great and there are good answers to all of them, but you have a LOT of technical and statistical questions.  I think you would be better served by buying a book like Heart and Hands by Elizabeth Davis, which is an introductory textbook for midwives but very readable for parents.  It goes over a lot of this information in a much more detailed and accurate way than what you will be likely to get here.  I am an info-junkie and reading this book when planning my homebirth gave me a basis of information from which to ask questions and also gave me peace that there is a "plan" in the event of an unexpected complication.

The other thing that's going to affect the answers is the specific midwife.  Skill sets vary among midwives, so you really need to know what the "right" answers are (for you) and then interview midwives and hear what they say.  Not all midwives are created equal.  For example, some midwives (in my state) carry pitocin and other rx drugs for PPH, and some don't.  You need to know what's available and what you are comfortable with when selecting a mw.

[MsBlack]

Originally Posted by MeepyCat 

.... The more I've looked at how long it takes to transfer, the more I am convinced that situations like placental abruption just can not end well if they occur at home.   

 While this may be true enough if the abruption starts well in advance of delivery, it is actually not true if the abruption occurs within the last minutes prior to delivery.  Most hospital crews would be unlikely to make the best response to a severely hypoxic baby in the early minutes/hours, and their actions could actually do more harm than good before they realized that they needed to be taking advice from whatever Level III NICU is in their region, having the best, most up to date info on saving the life and brain of such a baby.  I know this from experience with abruption occurring in the final minutes of birth-- a baby born at home whose life and brain were saved by being born at home, and thus NOT being subjected to the usual med protocols for neonatal hypoxia in the first 30 min--protocols that work well enough in many hypoxia situations but actually cause more damage in the most severe situations.  The problem is, it can take some time for labs and other assessment methods to show just what a baby needs.  The baby I know will now have the same chance as any other baby to grow up healthy and sound--BECAUSE she was born at home with a very late catastrophic abruption.

To be clear, a mw should know signs of abruption during labor, and transfer care as early as possible if abruption is suspected.   Despite my above comments, I do believe that if it is possible to get med help BEFORE an abruption is fully catastrophic, that is the best thing to do in spite of the risk of your baby receiving wrong care at med hands.  The possibility that you will be able to get med help before the worst is done, when the 'usual protocols' actually will be helpful, is worth the risk IMO.  My above comments only apply to last minute abruption during delivery--pretty rare but it is something that can occur without warning.

There is much that obstetrical and neonatal med care has to offer to those clearly at risk; unfortunately this is still very much emerging science and still riddled with myths and mystery.  None of us...not the best qualified docs nor the most-well-read mom or mw here...has solid justification for saying anything with too much certitude about this topic.

[Path2Felicity]

Originally Posted by womenswisdom 

Path2Felicity - All the questions you are asking are great and there are good answers to all of them, but you have a LOT of technical and statistical questions.  I think you would be better served by buying a book like Heart and Hands by Elizabeth Davis, which is an introductory textbook for midwives but very readable for parents.  It goes over a lot of this information in a much more detailed and accurate way than what you will be likely to get here.  I am an info-junkie and reading this book when planning my homebirth gave me a basis of information from which to ask questions and also gave me peace that there is a "plan" in the event of an unexpected complication.

The other thing that's going to affect the answers is the specific midwife.  Skill sets vary among midwives, so you really need to know what the "right" answers are (for you) and then interview midwives and hear what they say.  Not all midwives are created equal.  For example, some midwives (in my state) carry pitocin and other rx drugs for PPH, and some don't.  You need to know what's available and what you are comfortable with when selecting a mw.

Thanks for the reference, womenswisdom.  I will definitely buy this book.  However, I still would like to create a list like this as a resource so it's also easily accessible to people.  It can be a summary and doesn't have to be an exact science.  But, having a list of what could go wrong and being prepared with a general sense of what we can do about it (or, rather, what a trained midwife can do about it)... well, I think it's helpful to have.  I will do some more research on this today and post what I can find!

[honeybee]

In the book Baby Catcher, there are two descriptions of placental abruptions. One ends badly (it was a high-risk, planned hospital birth, but the abruption happened at home), and one ends well. But it gives a good description of how a mw should handle this emergency. I actually found it helpful to understand how this is handled from the mw's point of view. Also, it really does illustrate the importance of a good transitionary relationship between home and hospital. The mw was a CNM with transitionary care established in both cases. She had a good working relationship with the hospital, backup docs, etc. The first transfer was hellish and everything that could go wrong, did, with a lot of egos getting in the way of taking care of the mother and baby. The second transfer was smooth, and everyone worked well together... which is no guarantee of a good outcome, but certainly makes a huge difference.

I have a lot to say about continuity of care and the lack thereof in the US ans how that should impact decision-making for homebirths...but perhaps that should be for a different thread.

[honeybee]

My mw just posted a link to this video on FB... it's a discussion on how to deal with shoulder dystocia. There are several more videos there as well. Thought they might be helpful.

http://www.youtube.com/watch?v=xJIGAnkw26I

[msmiranda]

Originally Posted by honeybee 
I have a lot to say about continuity of care and the lack thereof in the US ans how that should impact decision-making for homebirths...but perhaps that should be for a different thread.

I can't speak for the OP but I would love to hear what you have to say on this subject.  I think it is totally relevant to the questions being explored in this thread.

[Path2Felicity]

Originally Posted by msmiranda 

Originally Posted by honeybee 
I have a lot to say about continuity of care and the lack thereof in the US ans how that should impact decision-making for homebirths...but perhaps that should be for a different thread.

I can't speak for the OP but I would love to hear what you have to say on this subject.  I think it is totally relevant to the questions being explored in this thread.

Agreed!  As people post more and more info, I will go back and update our list.

[Gladiola]

Originally Posted by Path2Felicity 
  However, I still would like to create a list like this as a resource so it's also easily accessible to people.

Just curious - what "people" did you have in mind here? My first thought was that you're trying to create the list to "sell" your friends & family on HB. Is that the case?