Originally Posted by 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? It is what they do immediately if they see a prolapsed cord in hospital too, the point being to keep the weight of the baby off the cord and prevent it from being compressed, they only lay you flat again as they administer the anaesthetic for the cs. Effectiveness depends on the position of the baby and cord, the dilation and descent and the experience of the person helping - outcomes are improved though even if the mother is alone and gets into this position.
2- How quickly does a transport to the hospital need to take place in order for a safe delivery? That again depends on the actual situation. A severely prolapsed and compressed cord which is not being protected despite knee-chest with manual help will damage a baby within 6 minutes and kill it shortly afterwards, but the chances of that happening are incredibly tiny - every occurrence is not the worst possible scenario afterall. A slight prolapse at the end of labour (ie if membranes rupture during the onset of the 2nd stage and the head descends immediately and pinches the cord) might do no damage whatsoever if the baby is born quickly.
3- What are the signs of cord prolapse? At what point should a good midwife start to think of transport? A cord in the vagina or in front of the presenting part during a VE is the main sign - a "hidden" prolapse, where the cord is pinched by the presenting part but still inside the cervix would be detected by worrying hearttones (either tachy cardia or bradycardia). Any sign of a cord and a good midwife would turn mama knee-chest and call EMS immediately UNLESS she was actually catching the baby already (i.e. noted the cord as membranes broke during same contraction head then crowned). Midwives have guidelines for heart tones too, depending on their situation (i.e. NHS MW's have quite strict rules they have to obey, but my IM is governed by only the regulatory body, so she is free to follow evidence-based practices and not fear-based ones). There are parameters of "normal" for heart tones and for most MW's very careful attention is paid if they are abnormal and transport is decided upon based on continued monitoring. For example my DD's heartrate was 188 during the last contraction before i began to push but dropped to 145 after the contraction ended. MW could see i was on the cusp of the foetal ejection reflex and waited one more contraction, during which i pushed her head from spines to crowned, and 2 contractions, 4mins, later she was out and salmon pink - she had a true knot, which was probably why descent caused an acceleration so high.
2. Placental abruption. solution: emergency transport to hospital, emergency c-section.
1- What are the signs of a placental abruption? Pain during gaps between contractions, abnormally long contractions (or belly always hard), "tearing" pain not near the cervix, abnormal foetal heart tones, sometimes abnormal bleeding.
2- When would a trained midwife know when to transport? Through experience alone. If an abruption is suspected EMS would be called immediately. Likewise if heart tones are abnormal care would be taken to monitor closely, and EMS called if MW became worried about them/another sign became apparent.
3- How quickly does a transport need to take place in order for a safe outcome? How quickly does it happen in a hospital? That depends, as ever on the individual situation. Mild abruption might not even be dxable before birth occurs, is very survivable and could even be dealt with at home (though of course wouldn't be, deliberately). Severe abruption is very rare but could kill the baby within 6 or 7 minutes and the mother in a few more. Babies die of abruption in hospital too, there is no silver bullet, in general if an abruption is dx they attempt to have the baby out within 15mins. Some babies born within that timeframe still die. There is a mama on here whose baby girl, Aquila, died of an abruption, but when you read her blog it seems to me clear that the MW was negligent. She delayed transfer when the mama wanted it, she ignored worrisome heart tones, she failed in her duty of care to that family.
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? Yes, for The Farm they have never had a dystocia which they couldn't free with the Gaskin move. They probably won't attempt it in hospital though, they move straight to McRoberts.
2- How tragic are the effects? They can range from none (baby unsticks and is born none the worse) through nerve damage (Erb's palsy is most common, causing weakness in affected arm) to death.
3- How often does this occur and how is it handled in the hospital? It occurs in about 0.5% of births and is handled in various ways from pre-emptive surgery (your bump is big/you gained too much weight/our ultrasound technician says the baby is large, so we'll give you a cs at 39weeks JIC), to McRoberts (mothers (on her back) legs are flexed right up to a "frog" position to open the pelvis, pressure is applied to lower abdomen (suprapubic pressure), sometimes foetal head is pressed/pulled on and usually a large episiotomy is cut, then Woods' screw method may be tried (large episiotomy is cut, dr puts his hands inside to push one shoulder back and the other forwards and attempt to corkscrew the baby out. The clavicles frequently break during this maneuver.) then possibly zavanelli's maneuver (head is pushed back inside, cs is performed but this is VERY rarely done as it almost always results in severe injury and possibly death to baby and mother). Most dystocia's which occur are positional, which is why the Gaskin move is so successful BUT in hospital most women have an epidural and cannot easily/quickly get onto their knees and stay there stable to push so they don't tend to use it in hospital. Very rarely Gaskin fails and then, at home, a MW will do what she can (mcroberts with suprapubic pressure if she has help (someone skilled has to manipulate the baby to avoid tis neck being injured, so she needs 2 others to push the legs flexed and a 3rd, experienced person, to apply suprapubic pressure) episiotomy and modified woods if she does not.
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? It depends entirely on the MW.
2- If a woman doesn't know her baby is breech and her midwife doesn't want to handle it, can she transport? It's unlikely she wouldn't know - a good MW could feel a baby was breech and would of course inform mama and talk choices. And yes, she could transport if she wanted to do so, and a MW who was not comfortable with breech birth would tell her that she was unable to assist and advise her to do so.
3- How often does head entrapment occur? I cannot find figures, but it should be noted that along with increased risk of baby being injured with the scalpel (9% with cs breeches compared to cephalic cs births) head entrapment is also a risk of breech cs births, because the uterus can contract down when most of the baby is out, closing the incision site around the neck. In this case they usually immediately administer general anaesthesia to the mother, to relax the uterus and free the head. So, again, there is no silver bullet for this one!
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? Some degree of uterine rupture occurs in around 0.5-1% of women with previous cs's AND in 0.5-1% of women having a medical induction with NO previous cs's. Food for thought - they will say you cannot VBAC due to the same level of risk they fail to even mention when booking you for an induction-purely-for-post-dates. Uninduced women who are not VBACing will have a rupture about 1 in 16849 according to a study mentioned here, though the actual link to the study doesn't work.
2- What are the signs of uterine rupture? Continuous pain at the scar site, non-reassuring foetal heart tones.
3- At what point should a transport to the hospital take place? Immediately if it's suspected.
4- How quickly does a transport need to take place for safe outcomes? As ever, depends on individual case - severity of rupture, etc.
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? I would expect anyone calling themself a MW would have this training.
2- How often are midwives not able to help a baby to start breathing again? When is a transport to the hospital required? Some babies need more help, as Ms Black has outlined so well. If the baby isn't responding within a few moments to attempts to help the EMS should be called.
3- I am assuming a quick transport would be needed. Is this something generally done at home before the transport? The MW begins to breathe into the baby if it is really not making any efforts itself, this may progress to intubation but usually isn't (it's a delicate proceedure in the newborn, usually done in the hospital, though some MWs/EMS can do it) most MWs would use a bag and mask, but whether it does or not, someone will continue to breathe into/for the baby until either the baby breathes spontaneously or a machine is fitted to do so.
4- What are the reasons for a baby not breathing? Can this be detected before hand? There are many, some babies are hypoxic due to unseen labour difficulties, some babies have been damaged by hypoxia during pregnancy and have no gasp reflex, some babies have unforeseen chromosomal disorders, some babies have malformations. Some perfect babies don't breathe, just as some perfect babies miscarry, are stillborn or die of SIDS. In some cases it can be predicted that problems may occur, in others it cannot.
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? This is where the placenta has adhered to the actual muscle fibres (not the endometrial lining) of the uterus, or grown into it or grown through it. It is vastly more common in women who previously had a cs and means the placenta cannot detatch and bleeding cannot stop. Chemotherapy (to kill the fast-growing uterine cells), surgery (to remove the affected are of uterus) and hysterectomy are on the cards for this complication. It can be fatal.
2- How urgent is it? When does this occur in the labor? It occurs during implantation/pregnancy and generally only becomes apparent later on during ultrasounds (or after baby is born if no ultrasounds are done). Placenta is usually seen to be low-lying (over the scar) and scanned to investigate why, but occasionally an unseen satelite lobe can attached there and be unnoticed.
3- How quickly is a transport needed for a safe outcome? Same as PPH, except that it's not likely at ALL to resolve at home.
4- What are the outcomes associated with this? As i said above, hysterectomy and death are a real possibility.
5- Are there any signs of this happening? Pre-labor it is usually only seen on scans, though percreta (where it has grown right through the uterus and into other organs) may cause other symptoms depending on the affected organs.
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. In around 5-8% of deliveries.
2- Are homebirth midwives generally trained in handling this? Yes, very much so.
3- How quickly does a woman need to be transported to the hospital for a safe outcome? Many minor PPH's can be dealt with at home. A PPH is defined as bloodloss of 500mls+. Up to 1000mls is considered a minor PPH, over 1000mls is a major PPH. This is not such a great rule of thumb - an anaemic woman may be fainting with a loss of 400mls, and a large healthy mama may not even notice a loss of 800mls. Clearly if the PPH is 600mls loss a mama may be just fine staying home once bleeding is slowed, and rushing off to hospital would be unnecessary and potentially dangerous (infection risk, leaving baby home, etc. etc.) For a large PPH the EMS would be called ASAP and timely transport would be ideal. Some women will not stop bleeding, despite pitocin, uterine massage and so on. But this is very VERY rare.
4- Are there signs that a mother could possibly begin to hemorrhage? There are certainly risk factors, interestingly placenta previa increases the risk by about 15 times, but planned cs increases it by 9 times, the next highest risk increase. Most risk factors the MW would have screened for and discussed (like previa, PIH, PE, obesity etc.), there is no way to dx it before it happens though. I would personally not feel safe using a MW who didn't carry and know how to use contractant drugs (mine had syntometrine, ergometrine and syntocinon).
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!