Planning "Unassisted" Homebirth (Under the radar midwife)--Need Advice!

[primipara]

Hello ladies!

I am 37 weeks pregnant with my first. She was conceived through IVF after two years of infertility treatments. I was tested for everything under the sun and ended up on blood thinners. My hematologist says my condition is mild, and the studies say that hemorrhage risks are no different whether you are on blood thinners or not. However 2 homebirth midwives turned me down for that. I tried to reconcile myself to a hospital birth and found some great OBs with an unbelievable 7.7% C-section rate.

Fast-forward--have had a dream pregnancy so far--thank G-d. Baby is head down and on the small side. But can't get used to the idea of being in the hospital. I have now found a wonderful, experienced midwife who is a friend of a friend who would be willing to catch my baby.  BUT 1) she's licensed in NJ not NYC 2) I'd have to be under her care for 6 weeks for her to deliver me legally. So the only option, if we want to stay home, would be to file it as an unassisted birth. Logistics aside, I and DH am concerned about the unlikely event of transfer. We are essentially making my doctors unwitting backups. What do we tell them if we're coming in after 40 hours of labor? Or what if we're transferring because the baby's heart rate has slowed, but we're not supposed to know that? 

IS there anyone who's been there, done that? Basically we're in a belt-and-suspenders situation, which I feel like is not a bad place to be, but also I have a strong intuition that this little girl, who was conceived at the hospital, wants to be born at home.

[dogmom327]

As long as you don't name her or say she was at your house attending your birth, I think she will be fine. You can always just say you were trying to labor at home as long as possible. That you had a doppler (you can rent them online btw) and noticed the heart rate was slowing, or that you've been in labor a long time, etc. If you have to transfer very late in the game you can always say you were trying to labor at home and then all of the sudden you things progressed and then you are now here for care and you've noticed xyz and are concerned.

[jenrose]

Hemorrhage risks ARE higher on blood thinners if you are on them at the time of delivery. 

[primipara]

Not according to these studies, as long as it has been 12 hours between your last dose and delivery:
 
http://www.ncbi.nlm.nih.gov/pubmed/18007136
http://www.ncbi.nlm.nih.gov/pubmed/17443203
 

"discontinuing Low-molecular-weight heparins at least 12 h before delivery seems sufficient to prevent post-partum haemorrhage."

"Bleeding complications, including PPH and transfusion, in patients treated with LMWH during pregnancy were not increased when compared to normal controls matched for delivery route."

[primipara]

and one more:
http://www.ncbi.nlm.nih.gov/pubmed/22102641

Conclusion Therapeutic doses of LMWH in pregnancy were observed not to be associated with a clinically meaningful increase in the incidence of PPH or severe PPH in women delivered in this hospital.

My midwife has been working overseas in a clinic where almost half of women have some excess bleeding, so she is very very experienced with prevention.

[quantumleap]

Does she carry pitocin? Oxygen? This is just my personal take on things, but if you decide you need something for PPH, you don't want to dink around, you just need the drugs! After my last birth, I will also have to think very, very hard before birthing at home without O2. Thank heavens my son was not impacted long-term, but he really would have done a lot better with some O2 at birth (dystocia, very, very grey baby). That said, I did give birth at home with a midwife not trained/legislated in our province and I would do it again (we had pit, just no oxygen). We did have to go in after the baby was born because I had some significant 3rd degree tearing into some important areas and the midwife wasn't confident that her repair would be as good as a repair done by an ob who does such things all the time. Our area is not in any way unassisted-friendly or anything, but we got absolutely no grief at the hospital about how we had done things. 

I wouldn't worry too much about if you have to transfer. Just be honest, tell them  you're concerned about xyz because of abc. It's not as though you'd be the first person who laboured at home for a good while! The pp's suggestions are exactly what I would do too. :)

Hope it goes really well! 

[primipara]

Thanks for your responses! Yes, MW does carry both pitocin and oxygen and is experienced with resuscitation as well. At the overseas clinic where she has been working they haven't been able to transfer anyone to a hospital for the last six months, because the roads have been so bad, so she has dealt with some pretty harrowing situations. I and DH will probably be much more conservative about transferring than she would be. I have no problem doing it if I am simply exhausted.

[anjelika]

I delivered my second child in August, and have been on anticoagulants since February 2008.  If the hospital has a low c/s rate, deliver there.  LMWH and standard heparin react differently in each body and unless you have a clotting test done that day, you have no idea what your personal risk is.  Are you on anticoagulants prophylactically or therapeutically?  If it's just a preventative measure (positive thrombophilia panel with no history of clots), I'd talk to your practitioner about going off the meds before birthing at home recently anticoagulated.  Also, the clotting risk goes up after birth for 6 weeks.  Safer to have the anticoagulant restarted by a specialist.  Lots of things to think about besides just PPH.  Hospitals can be natural birth friendly if you work with them beforehand - no such guarantees as a transfer, unfortunately...

[primipara]

I'm on them prophylactically. Switched from Lovenox to shorter acting Heparin last week.

Risk runs in my family. Specifically I have tested high for lipoprotein (a) which is not part of the standard thrombophilia panel, it's a genetically controlled variant of cholesterol. It's normally thought of just as a heart attack issue, in which case the targeted level is 50; but the ideal level is 30 or below. Mine was 44. The hematologist already said she would not have to put me back on any injectables after birth, I would only need a baby aspirin from here on and to watch my regular cholesterol (which is quite low).

From what I've heard, it happens a lot these days with IVF that the doctors get a little zealous with the blood thinners, because it is one of the few

early miscarriage risks that's understood and controllable.

But thanks for giving me another side to think about.

[jenrose]

Yes, the key is "12 hours to the last dose". 

My last labor was less than 4 hours from my first contraction to the baby out. So I reiterate.... there is an increased risk of hemorrhage *if you are on LMWH at the time of delivery*. If it's been more than 12 hours from your last dose, you're not still "on it at the time of delivery". 

I just dq'ed my lovenox because I started prodromal labor at 35 weeks, as I always do, and while we've got an excellent chance of me making it to my due date, the fact that when labor gets going, it goes FAST means that having contractions while on lovenox makes me damn nervous. I'm doing a food-based protocol now.

[Adaline'sMama]

Quite honestly, I think at 37 weeks pregnant and being on blood thinners without a licensed midwife you should probably stick to your (amazingly low rate of csections) OB at the hospital. Have you read Homebirth in the Hospital? It is a great read for people who really do want a homebirth and have to reconcile with a hospital birth. It just seems pretty late in the game to be changing your plan and but if you have no problem transferring if you are simply exhausted then it sounds like you will transfer the moment anything goes wrong anyway. I think that is smart, but be prepared that the hospital wont be as receptive to your natural birth plans.