Back Up Plan for a Home Birth

[Mawood]

Hi -

I am currently 14 weeks pregnant with my second baby. We just met with the midwife I would choose to have a home birth with and I think I feel comfortable with a home birth except for the fact of the lack of a back up doctor. She has a back up but he is not in any of the hospitals close to where we live. We live in LA county and depending on traffic it does not seem practical to drive from one side of town to the other in case of an emergency. The OB I am having and who attended my first birth is natural birth friendly (meaning unmedicated) and did back up for midwifes until 1 1/2 years ago. However he does not do that anymore and I had just talked to him about it at my 10 weeks visit as I had mentioned that I am thinking about a home birth this time. So the midwife and my doula from last time suggested to just not mention a home birth to him anymore and keep doing prenatal visits as it is already approved by my insurance and in the case of the need of a transfer to go to the hospital and give him as my OB. I feel very uncomfortable about doing this though my doula and the midwife said the chances of needing a transfer as a second time Mom would be very slim. The midwife had only had two transfers of second time Moms in 10 years. I just know that I probably will be wondering about this all pregnancy if I decide to do a home birth. I couldn't lie into my doctor's face if he would for example remember and ask me about my decision. It would be convenient to use him that way as we have HMO and could not even pay the far away back up dr. who isn't in our insurance just like that hospital isn't in our medical group. It is so confusing to deal with all these insurance matters as I am from Germany and we have a way easier and patient friendlier health care system. Anyways wouldn't it be obvious that I tried for a home birth let's say if anything seems wrong while already pushing and we 'd do transfer then?

I don't know. What do you think?

Thanks so much, HTH Maren

[womenswisdom]

I would ask your midwife what the plan would be if you were to need to transfer for an emergent situation. I would doubt that she would expect that you would travel a long distance for a true emergency and would instead transport you to the closest facility that does L&D. Most transports, however, are not emergencies per se, and transporting to a friendly backup who is further away would be more practical. If you need care in a true emergency, you can show up to any hospital and they will provide care for you even if you don't have an OB at that hospital. It wouldn't be ideal, but it would be doable.

[nikkijames]

I agree with what the PP said. Also, I would make sure it's your midwife's policy to accompany you to the hospital in the event of a transfer. In a true emergency, you are going to get whoever is on call at the nearest hospital, in all honesty. I would be comfortable with that as long as I trusted that my mw would be with me.

[LindyGirl]

I agree with the PPs. A back up doctor is mostly used in the event that she needs extra help regarding your health prenatally, that you need a procedure that she doesn't feel comfortable doing (say, an external version to turn a breech baby), you need access to tests she can't order, or you need a scheduled C-section.

There are a couple of different reasons for possible transfer away from homebirth. One is that you're getting exhausted, baby isn't sounding perfect/etc, and you need to transfer to get some pitocin or some pain relief or to have the baby monitored more continuously. Usually, these are transfers where the mom and MW make the decision together, and they're usually not true emergencies, just the best decision at the time. In that case, you might go to the hospital that's farther away to work with her backup doctor, but that would still be your choice. Ultimately, you absolutely have the right to refuse and go the hospital you want.

The other transfer scenario is a true emergency, where something like a placental abruption is happening. In that case, I can almost guarantee you that the MW will take you to the nearest hospital, where you will probably just get the on call OB. Time is of the essence in those scenarios.

I would check with her to be sure, but I can't imagine she would want you to drive 1+ hours in a true emergency.

[Mawood]

Thanks for your feed back. My MW said exactly what you all said. In a true emergency we would transfer to the nearest hospital and for other transfers she recommended I use my OB and the hospital which is already approved to save us the money for her back up who only takes PPO. My concern is that my OB who I would visit parallel for pre natal check ups so he still thinks of me as his patient did tell me he does not back up home births. If we mutually decide me or the baby needs something and we transfer to the hospital wouldn't it be obvious that I was trying for a home birth and am just using him as a back up though he told me he can not do that anymore due to his insurance etc? I think that is the part I am uncomfortable with as I think if I arrive with a MW, doula late in the birth we will be treated badly or I 'd feel weird for having lied to him. It would be a bad basis for him supporting my birth. Am I over thinking this? Is it likely to happen like this? is that a risk you would take?

Thank you, Maren

[LindyGirl]

If you arrive at the hospital in a true emergency, it would be very unlikely that you would get your current OB as your doctor -- you would get whomever is on call and available to take you immediately. They would not wait until your OB could get to the hospital, although he may come see you afterward when he does rounds. In other words, you're not using him for backup, really. You're using your local hospital for backup.

[Mawood]

Thanks LindyGirl. Is that a common practice that you just have the local hospital as the back up? Our nearest hospital unfortunately is very "unnatural" and high interventive. I had my daughter there and even my OB says now that he doesn't recommend it for natural/unmedicated births. He also delivers in a hospital in the next town and that is suppose to be way more Mommy and Baby friendlier and is where I would deliver with him now. I can only imagine how they would treat me if I would be transferred to that closest hospital after trying for a home birth as they were giving us already attitude when we checked in last time and I was completely dilated and pushing 4o minutes after being submitted to the LDR :(

Is that normal to worry so much about the transfer while trying to decide for a home birth? 

[BroodyWoodsgal]

Originally Posted by Mawood 

Thanks LindyGirl. Is that a common practice that you just have the local hospital as the back up? Our nearest hospital unfortunately is very "unnatural" and high interventive. I had my daughter there and even my OB says now that he doesn't recommend it for natural/unmedicated births. He also delivers in a hospital in the next town and that is suppose to be way more Mommy and Baby friendlier and is where I would deliver with him now. I can only imagine how they would treat me if I would be transferred to that closest hospital after trying for a home birth as they were giving us already attitude when we checked in last time and I was completely dilated and pushing 4o minutes after being submitted to the LDR :(

Is that normal to worry so much about the transfer while trying to decide for a home birth? 

In my (personal) experience....the worrying about transferring gets a bit more intense each pregnancy. There is something about meeting, getting to know and loving your baby...that makes you a bit wary of the risks in subsequent pregnancies. This is my third baby and I'm much more aware of and thinking more about the risks associated with pregnancy, birth, etc....not all women are like this, but for me, each pregnancy I've spent more time "planning" for backups, etc.

I don't personally see an OB for anything...I see midwives exclusively for all of my pregnancy, birth and gyno needs. If I need to transfer in a non-emergent situation, I would go to the hospital where my midwife has the best OB relationships (and where the OB she uses as a "back up") works, just because then it makes it easier for her to advocate, stay with me, etc. In a truly emergent situation, I'm going where the ambulance can get me quickest. Period. I don't care if Doctor Fish Hooks is working the night shift there...if I'm rupturing or having some other really scary problem, I just need to be close to an operating room. Period. You know?

So, unless you are getting "ooky" feelings about the midwife for other reasons, I'd feel really good about this and try to make peace with the planning you've done for this part of the plan. I would, perhaps after the 20 week scan, if you're planning to get it.....graciously thank your OB for his care and advice, advise him that you are having a homebirth and so, do not expect that he will continue to want to see you...and spend the rest of my pregnancy with the MW....and, should something comes up that "needs" an OB, she has got her OB to consult with and/or refer you to.

Your birth is going to be great...you're going to love it. In the event that an emergent transfer is needed, you will get to the closest hospital and you will receive emergency care. In the event that a non-emergent transfer looks like it's the best idea....you will travel to your MWs preferred hospital where you will be treated well, your MW will be able to stay with you and the OB who helps you will be supportive of what you were trying to do at home and, unless something is really turning sour, they will most likely support your continued try for a natural birth.

^That sounds like a really solid back-up plan for a homebirth. Seriously. You have thought about this as much as you should....and again, so long as you feel tight with this midwife....you have made a good and solid plan. I think you're being smart about this and I think you can feel peace about this part of your plan and move on to the next piece of planning.

It's important to plan, but I also try to remind myself not to "plan to death" the things which cause me to focus on vague, negative things that exist only as possibilities in the far off future. I'm not encouraging you to ignore your gut, IF your gut is trying to talk to you....but I also know that in certain phases of homebirth planning, there are places you can get stuck in spiraling patterns of "what if" thinking...and that those are not incredibly helpful places to stall out when you are SOOOOO far away from the reality of your birth.

Everything is okay. You are months away from your labor....nothing is going wrong. Everything is going to be great, you know how to do this, your MW is capable and supportive and your plan is a solid one! Your worry is normal, but process through it, don't get bogged down....there is so much to think of, so much to plan, this is only one small piece of your homebirth preparation. <3 <3 <3

[Lovebeingamidwife]

The truth is if you're back up for an emergency transfer is "unnatural and high interventitive" it might be the best option. An emergency transfer to the hospital means you NEED interventions that can be done in the hospital. If they are known for being 'interventive' that means they are good at it and you'll get the care you need. Emergency transfers are no longer about being 'natural'. Does that make sense? Sounds to me like you have a great backup hospital!

[cristeen]

Just a little information about terminology for this state.  It used to be that CPMs had MDs who were their back-up, in that they worked exclusively with that MD, and if there were problems, the MD could step in, consult and/or take over care.  Because of malpractice insurance issues, now no CPM in the state of CA has OB backup.  None of the malpractice insurance companies will insure a doctor who works with a CPM. 

You are not asking your OB to be backup to your MW.  You are pursuing parallel care.  They are different.  Back up is actually a complex legal issue surrounding a long-term ongoing relationship between care providers.  Parallel care is about patient choice.  You are completely within your rights to continue care with your OB and tell him or not at your discretion about your HB plans.  What he was telling you in his way was that he has worked with midwives in the past, is comfortable working with midwives, believes in the work of midwives, and the only reason he no longer works with them is because his insurance company dictated it. 

As for showing up pushing and the OB being curious - women show up pushing all the time.  Whether they're having precipitous labor, or chose to stay home and misjudged how far along they were, or they wanted to avoid the interventions inherent with laboring in a hospital.  Doesn't matter.  It is your right to go to the hospital when you're ready to - but like the pps said, be aware that the chances of you actually getting your OB in a transfer situation is slim.  You'll get whoever is on the floor at the time. 

[Mawood]

Thank you so much for all your responses. It has been great support. Thanks a lot Cristeen for your clarification of the terms and laws. This has helped me a lot to understand the doula's and midwife's thinking and is a great relieve to know. I feel much more comfortable now!!!

Wow, so the Californian laws make it impossible for OBs to work with midwifes and learn from each other. It seems like it is going that direction with home births in Germany as well (like it is harder to find a midwife because the insurances for a midwife practicing home births is becoming so high that most midwifes can't afford it or have to charger high fees - probably like here), but the two professions still work hand in hand in hospitals and all the postpartum care is provided by midwifes on insurance. 

Thanks again every one. It has been very helpful to me!!!!!

HTH Maren 

[cristeen]

It's actually not the law.  It's the insurance companies being butt-heads.  The law actually dictates that CPMs are supposed to have OB backup, but the insurance companies make it impossible.  It's a huge mess, not helped at all by the fact that many doctors are in fact feeling threatened by MWs, feeling they're encroaching on territory. 

I'm glad that helped, though.  I was hoping it would.  :)

[joycnm]

Here in the US the laws regarding midwifery are unfair in many states.  In New York we fought this Catch 22 law stating that midwives needed a back up doctor yet there were rare cases that a midwife could find a back up doctor. Therefore this law caused a restraint of trade--we could not practice our trade legally if we couldn't find a back up doctor so the law was causing us to be unable to practice midwifery.  We fought and won this fight 1-2 years ago.  But, still, we have to play "games" with the OBs because that is how they prefer it!!!  To actually say, "Yes, we'll back you up." makes them think they are open to liability.  It's called the Myth of Liability.  Where I practice, the doctors actually prefer us coming in without previously meeting the patient because they "believe" it reduces their liability.  Mark my words--"believe"--because they have NO liabiliity if the patient is seeing a midwife.  Also, the emergency scenario...there is a federal law (a law all states have) called EMTALA (Emergency Medical Treatment and Labor Act) that states that no patient can be turned away from ANY hospital in an emergency.  They have to take you.  Now, as you've suggested, the hospital personnel doesn't have to like it.  The reception you get from any one nurse or doctor is very individual, and sometimes can be hospital specific.  Did you say you you received "attitude" last time at the very hospital you plan on using for transfer this time or did I misunderstand?  Also, the chance that the one and only physician you are seeing for prenatal care will be on duty the day you need hiim/her is very remote.  This is the reason women choose home birth; you pretty much know who will be attending your birth.  When you go to a hospital, you never know who will be there.

[Comtessa]

FWIW, with my first birth I did parallel care with an OB who was covered by my HMO.  Your OB sounds a lot like mine -- basically, supportive of what I wanted to do, but couldn't "officially" back up my midwife.  I was honest with him -- I just said, "if I have the baby, I'll call you, and if I call you before I have the baby, it's cause I really need you."  That honesty worked in my favor- - when I ended up needing a non-emergent transfer, he actually came in (on his day off) (at 5 am) to be there for my birth, since he knew I did NOT want to be in the hospital and that the hospital staff would NOT be supportive of my home birth plans.  

[Mawood]

@joycnm: Yes, I did get some attitude when I arrived at the hospital last time. I was already completely dilated and almost ready to push. I was actually surprised when they checked my dilation but my doula said she thought she had heard me bearing down my daughter. So the LDR nurses seemed annoyed with me and the doula. She had to sign a paper that she wouldn't interfere with the birth or she could have been sent out. My doula said she had never had to sign a paper like that. So that is the closest hospital to my house and would be the one in a true emergency :(

There is another smaller hospital in the next town that where my OB also delivers and that hospital has a great reputation and is suppose to be very baby friendly. I already have an approved referral for that one with my old OB as his office was really quick. I think I got it at 10 or 12 weeks so we would go to that hospital for a non emergent transfer.

@Comtessa: That sounds really like a wonderful doctor. With my OB I am not so sure. Maybe I will do something like that along the way, but just from my last birth experience I left wondering why he would support natural birth because it truly didn't seem like his passion and I didn't find him very compassionate. I came in very late and my daughter was crowning very soon after I was submitted to the LDR. My OB wasn't in the room when that happened and all the nurses got very hectic. He did put me in stir ups right away and was giving me all kinds of commands. What happened is that my daughter went up again. My doula said she had never seen anything like that (she has 15 years of experience), but I had a hard time pushing and ended up with an episiotomy. My doula did have another birth with my OB and said he was very supportive of that Mom having a VBAC, but she also said that she didn't think he was handling my birth well. I think I would have pushed my daughter out easily in a different environment and truly believe that the hospital transfer and the attitude we received (my OB seemed a little stressed too upon the late arrival and had another Mom next door pushing as well) made it so hard. My daughter led meconium and I am sure she did that during that last 40 minutes or so when she went up again. So I was pushing and there were the nurse and two other nurse practitioners waiting with the suction table. They would play with their phones in between my contractions and I felt really removed. After the birth I got to hold her 25 minutes and then she had to go to the nursery for 4 hours because she had low glucose levels. That last two hours of my birth and those four hours that my daughter had to be in the nursery were giving me a hard time postpartum and I cried and grieved a lot though my OB didn't have to do anything with the nursery. That was the pediatrician. 

Thanks again for all your thoughts and support!!