Back up care?

[mija y mijo]

This is going to be our first homebirth and I'm curious as to whether or not we should have back-up care lined up in the event that I need to transfer - either during the pregnancy or during the birth.  One of the moms in my Bradley class mentioned having an OB/hospital back-up and it made me think.  Do you have a relationship with an OB/hospital even though you're planning a homebirth?

[LaurenAnanas]

I don't have an official backup provider or relationship with a hospital.

That said, hospitals in the USA are required by law to admit and treat women in labor (http://en.wikipedia.org/wiki/Emergency_Medical_Treatment_and_Active_Labor_Act, a.k.a. EMTALA) so I have no worries about being refused treatment. Whether I would get top notch treatment, isn't that always a risk? If a complication arises prior to labor, I'll deal with it when it happens.

My closest hospital has pre-registration forms online and I have printed one out and stuck it in the emergency folder for my husband, in case we do have an emergency transfer. Also have a form for the not-quite-as-close-but-a-little-friendlier hospital in case of a less urgent transfer. I could even send in the pre-registration forms if I wanted to, so I'd already be in their computer system. But I don't want to.

If I had a prior relationship with an OB that I trusted, I might consider minimal shadow care or a consultation, but I've never even seen an OB/GYN, only family practitioners and midwives. An official relationship with an OB is just one of the things I hoped to avoid in choosing homebirth, but if that's what you feel comfortable with, then go for it. I'm sure some women think my packet of emergency transfer forms is too much!

[Peony]

I never have, I don't see the need for myself. The hospital will treat me, I can say I have a provider, they just can not attend the birth at the hospital. If you had an established relationship with on doc then there are no guarantees that doc will be on call if you should have to transfer. So then you are back to getting just an OB who is on-call or there. 

[MegBoz]

This is so SOOO tricky. Best case scenario - it would work function the same way it doesn't with MWs who work in a hospital collaborate with their back-up OBs. They work together, respect one another, would share records & the MW would CONTINUE to provide support to mama as things escalated with OB involvement. You could also meet the OBs at your prenatals if desired.

Unfortunately, very few HB MWs in the US have "official" OB backup. (Well, and even if mine did, I can't imagine she'd have so many back-ups that she would have relationships at every hospital her clients could transfer to! There are 7 hospitals with L&D just within about 30-40 min of my house!)

I think my MW has maybe one friendly doc, but he's not near me. Fortunately, the hospital closest to my house also happens to be one of the best 2 in the area for NCB and I already had my DS there, so I know the MWs myself. Also fortunately my HB MW has a very good relationship with the MWs there. I consider myself lucky that I have only 1 transfer hospital - I know of others that have 2 - the closest hospital in an emergent transfer, and a farther away, more-NCB friendly hospital in case of non-emergent transfer. (I would do that too if I lived about 10 miles west, with GBMC as the closest hospital to me. That would be my LAST place to transfer!)

For this PG, I have seen the CNMs at my transfer hospital a few times. My MW is a CPM & thus illegal in Maryland. I thought it would be easier to get some of the testing I wanted anyway by going through the CNMs, plus I could "establish" care & hopefully ease transfer. My CPM does recommend 'establishing' care for all her clients & has encouraged me to 'maintain' the relationship in case we end up needing to go there again for further testing later in the PG.

It's been tricky - I ask to see only 2 of the 5 CNMs who I know are friendly. (of the other 3, I haven't met 2 since they weren't there when I had my son in 2008, and 1 I know is NOT friendly to HB and much more medically minded.) Those 2 ladies tell me they won't put it in my chart that I'm planning an HB in case the OBs might give them a hard time.

I refuse to do full on "shadow-care" because I don't have the time for all the prenatals at BOTH places - but also because my insurance will cover my HB, but I can't expect them to pay the global fee for prenatal, L&D & PP care to the CPM plus pay a bill for prenatal care with CNMs. So I'm trying to go occasionally- keep the relationship, but stay "off the radar" so they don't notice I haven't been in as much as I should. (That is what one CNM told me to do - come in a few times from 20W to delivery.)

My next apt there will be at 32W (next week) - I was last in at 20 W, so that's 2 missed. I don't plan to come back again after that. So I have to hope that if something concerns us at 38 or even 41W they won't have "fired me" as a patient & I can come in for an NST or whatever if needed. They did already once call me & send me a letter around 28 or 29W because I hadn't been in since 20W & hadn't scheduled an apt yet (I deliberately didn't schedule an apt, because asking for an apt 12W in the future when I should have scheduled it 4W in the future would obviously have been red flag!)

It's a hassle and, as stated, I'm worried what will happen when I don't show up again after 32W if I DO need to come back later. (If I don't need any other testing, I do not plan to come back to 'check in' around 38W or anything.) BUT - I feel like it might be slightly less stress if I do transfer, so I think it's better to do it, rather than to come in as a total stranger.

If nothing else, I think it might be wise tour your transfer hospital (hospitals?) & get familiar with their policies. Of course, "policies" such as under what conditions you can use the tub in labor, continuous EFM, IVs, etc. are less relevant than if you were planning hospital birth because in the case of HB transfer, you transfer because you NEED medical intervention, so you're probably not going to even want to, or be able to, deny things like an IV. But I'd get familiar with stuff like episiotomy rate & under what conditions they do them, if I could have skin-to-skin post CS, all baby care stuff (mandatory nursery stays? mandatory NICU stays under certain conditions - like GBS+ & no antibiotics, frequent sabotage of BFing by giving formula?) & have a transfer birth plan written up.

ETA - one more complication & worry I forgot to add to my saga is that I don't even KNOW if the CNMs could treat me if I transfer. :( Obviously if I transfer for something that requires OB care - say cord prolapse necessitating a CS, my 'relationship' with the CNMs isn't too helpful. Although at least I'm hoping that relationship might mean I'm less likely to be treated with hostility. If I come in for something where the CNMs could still be part of my care, I don't know what their policies would be since I would be an obvious HB-transfer at that point (Having my CPM accompany me, and not having come in for the weekly apts from 36W on.)

I know some people who do full-on shadow care - so the hospital-based provider potentially might have no idea they were planning an HB! So if they show up in labor, the hospital wouldn't even know it's a transfer. I'd say that's one way to ensure you're not treated with hostility, but as I said, too much time & effort for me personally & I can't expect insurance to cover complete prenatal care both places anyway.

[Full Heart]

If its shadow care and you are ok with getting twice the prenatal appts and dealing with all the tests an OB will want to offer then I don't see why not.  But you we will be in medical machine then.  If its an OB that works with mws, that can also be tricky.  Mws often can only do things that the OB will allow.  I experienced that first hand and when I found another mw I made sure she wasn't working with any obs.  When I transferred last time I had no OB and had no problems at the hospital I went to.  I was treated with respect (way better than the hospital experience I had with an OB I was working with) and got much better care.  So for me, I don't think back up is necessary and would rather go without.  But I can see how it can be desirable. 

[CBEmomma]

Yes. For my homebirth I had a back up OBGYN who I also saw, and a back up hospital. My area is pretty homebirth friendly, and there is a MW who actually works with a lot of the women who go to that hospital. However, I didn't know about her until after I had my ds2, so I might use her next time (nothing bad to say about the MW I did use or anything). Anyways. Yes I had a back up OB who knew of my plan to homebirth and was supportive.

[BarefootScientist]

I don't as of yet (I'm 19 weeks). But I am planning on finding a family doctor soon. We moved to the area last year and have not found a doctor yet. I like to have a family doctor just for everyone an everything in my family - my son will need a checkup soon, and someone to take the baby to after the homebirth, just for everyone's preventative care and in case we get sick or whatever. So when I find this person (and hopefully I will be able to find a good one!) I am planning to maybe do a few prenatal appointments with him/her, maybe get an ultrasound with the practice, etc. and then if I transfer at least I will be able to say that my doctor is Dr. X and I'll be "in the system" so to speak. My midwife is a CPM and I don't think she can really work with the hospital, they wouldn't recognize her records and so would see me as having no prenatal care, etc.

So that's my plan.

[Mamatoabunch]

I have had 8 HB's and never had backup OB care. I figured if I was going into the hospital it was b/c I knew I needed a c/s, unbudging transverse baby, prolapsed cord and any surgeon would due in that emergent situation.

[sellendie]

How many visits will the typical OB allow you to miss and still be considered a patient and "compliant"?

[RoseRedHoofbeats]

I'm doing dual-care with the CNMs at the hospital I gave birth at last time, since those prenatals are free and I can get all my tests and ultrasounds for free. My homebirth midwife is willing to see me less often to reduce what I'm paying her. I really love the CNM I saw last time and I wanted to include her in this pregnancy. It's also really nice because they're great about calling prescriptions in for me when I need something for nausea or yeast infections or whatever, and their emergency L&D is free as well if I'm a patient in their system. Also I feel better knowing if I transfer that I am still her patient and that she can have charge of my care, as opposed to showing up and being at the mercy of some random OB on call.

~Rose

[mija y mijo]

I decided to call and make an appointment with the OB that I've heard great things about.  The office asked who my current care provider was and what I was looking for and when I gave them my midwife's name and told them I was looking for shadow care they scheduled my appointment, so that seems to be a good sign!

[SynEpona]

It's so different in the US than it is here in Ontario (Canada). Our midwives are covered by our provincial healthcare, and you choose one primary care provider -- either MW or Fam.Doc, or OB/Gyn. The schedule of appts is roughly the same (all bills paid by the Gov't), and the midwives can deliver at home or in hospital. If a transfer of care to an OB is needed, the M/W still provides emotional support & is still available to the patient/client. However, if a transfer from home to hospital is needed/wanted, the midwives can admit the client, and deliver the baby in hospital.

It's really interesting to read how differently it works throughout the US.

[Full Heart]

SynEpona - the stigma of hb here is terrible.  The ACOG is against any ooh birth including birth centers so most insurance won't cover it and many drs won't see you.  I had an ob through my 4th pg who was supportive of hb.  But when I went into ptl during my 3rd he was on vacation and his back up refused to see me (this was in the hospital).  I had a student see me.  It was really awful, she had never even used a speculum before.  

Mija y mijo - thats really awesome.  I hope the appt goes well.