or Connect
Mothering › Mothering Forums › Pregnancy and Birth › Birth and Beyond › Homebirth › Apgar Score of Zero at Five Minutes
New Posts  All Forums:Forum Nav:

Apgar Score of Zero at Five Minutes - Page 3

post #41 of 129
Thread Starter 
Quote:
Originally Posted by IdentityCrisisMama View Post

Did the article discuss whether transfer had been completed or initiated? 

 

It did. It said: "The CDC does not categorize as out-of-hospital births those hospital births that resulted from transfer from out-of-hospital settings where there was an intention for out-of-hospital birth."

 

And: "It is essential to note that these significantly increased risks of adverse outcomes from the setting of home and from the setting of free-standing birth centers reported here may be serious underestimations of clinical complications. A substantial number of the adverse outcomes attributed to hospital births result from transfers from home births."

 
"In the Birthplace in Britain study, up to 45% of nulliparous patients were transferred to the hospital. In the CDC data set the outcomes for patients whose care began out of the hospital but were transferred to the hospital are counted as outcomes of care in the hospital. They are not reported as outcomes of the original out-of-hospital setting. Obviously, correction of this factor would further negatively impact the relative risk of all adverse outcomes for births out of the hospital."
 
"We emphasize that the increased risks of poor outcomes from the setting of home birth, regardless of attendant, are virtually impossible to solve by transport. This is because total time for transport from home to hospital cannot realistically be reduced to clinically satisfactory times to optimize outcome when time is of the essence when unexpected deterioration of the condition of either the fetal patient or pregnant patient occurs."
post #42 of 129
I sure would like to read the full article. Will someone please link when it becomes available to the public?
post #43 of 129
Another thought... Does the study indicate longer term outcomes? With these small sections I'm wondering if this study is really new info or another way to look at stats we already know. What percentage of birth death have a 0 five min apgar? Out of curiosity what % survive with low morbidity?
post #44 of 129
Pillowy, would you be willing to PM me the PDF or quote the conclusion here?
post #45 of 129
Thread Starter 
Quote:
Originally Posted by IdentityCrisisMama View Post

Pillowy, would you be willing to PM me the PDF or quote the conclusion here?

 

Sure, here's the conclusion:

 

"Conclusion
The increased risk of 5-minute Apgar score of 0 and increased rates of seizures or serious neurologic dysfunction of out-of-hospital birth must be acknowledged by all obstetric practitioners and should be disclosed to all pregnant women who express an interest in out-of-hospital birth. In addition, physicians have the professional responsibility to recommend against planned out-of-hospital births to women who express an interest in it and not to refer their patients to randomized controlled clinical trials of hospital versus out-of-hospital birth as ethically unacceptable. Physicians also have the professional responsibility to address the root cause of patients’ motivations for out-of-hospital delivery through continuous efforts to address patient concerns about interventions,35 and to improve compassionate and safe care of pregnant, fetal, and neonatal patients in the hospital setting."
 
I'm going to try and post the whole study below, for everyone who wants to read it. It might take a couple posts.
post #46 of 129
Thread Starter 

I have the full study for anyone who PMs me! :)


Edited by Pillowy - 7/7/13 at 8:28pm
post #47 of 129
Quote:
On the other hand, in out-of-hospital settings, most antepartum deaths in planned home births would be transferred to the hospital.

 

It would be really helpful to know what data they are basing this assumption on. Personally, unless I needed to be induced because I was at high risk for infection myself, I would not go to the hospital to birth a child who had already died. I would want the utmost privacy for that time.

post #48 of 129
Quote:
Originally Posted by fruitfulmomma View Post

It would be really helpful to know what data they are basing this ...
This is something I've read and the explanation made sense - I think it had to with monitoring an availability of c section in hospital.

Ptlillowy, thanks for posting the entire study! There sure is a great deal to discuss both from the perspective of understanding HB but also from the perspective of how this info influences our choices as home birthers.

Unfortunately, I have to ask that you remove the study for mothering copyright guidelines. You may PM copies if you choose.
post #49 of 129
I didn't read all the comments so someone may have already pointed this out but: This study was based on preemies. It says less than 37 weeks gestation, etc. Also this study was criticized by actual researches for not being well conducted. It's based on data collected from birth certificates. It could even have included those who had a fetal demise and planned to birth the baby at home.
post #50 of 129
Quote:
Originally Posted by YogaAndBirth View Post

I didn't read all the comments so someone may have already pointed this out but: This study was based on preemies. It says less than 37 weeks gestation, etc. Also this study was criticized by actual researches for not being well conducted. It's based on data collected from birth certificates. It could even have included those who had a fetal demise and planned to birth the baby at home.
It says greater than or equal to 37 weeks.
post #51 of 129
I thought it said over 37 weeks?
post #52 of 129
Can
Quote:
Originally Posted by YogaAndBirth View Post

Also this study was criticized by actual researches for not being well conducted. It's based on data collected from birth certificates. It could even have included those who had a fetal demise and planned to birth the baby at home.
Can you provide some sources for this?
post #53 of 129
Quote:
Originally Posted by YogaAndBirth View Post

I didn't read all the comments so someone may have already pointed this out but: This study was based on preemies. It says less than 37 weeks gestation, etc. Also this study was criticized by actual researches for not being well conducted. It's based on data collected from birth certificates. It could even have included those who had a fetal demise and planned to birth the baby at home.

 

I think you misread the text. It EXCLUDED premature babies.

 

" We excluded pre-term births (<37 weeks), infants weighing under 2,500 grams, and multiple gestations. This study therefore includes only singleton term births (deliveries ≥ 37 weeks) and infants weighing ≥2,500 grams. "

post #54 of 129

Identity, as far as I can tell, this number is artificially lower than it should be, because the "home birth, midwife" only includes the births that actually have the midwife as the attendant of record.  This also would perhaps hide home births with a midwife due to states where home birth midwifery is illegal, so the birth is recorded as an unassisted birth.  Those numbers are probably worse and they are not included in the "10-18x higher" risk.  

 

Any emergency transfer should go into the "hospital, MD" column.  Further, I believe that any birth that happens with paramedics in the field, or possibly even any birth where baby is out but placenta is delivered at the hospital would go into "hospital, MD."  At some point, it sort of becomes a question of how confident we are in the skills of the home birth midwifery community to correctly identify fetal distress and transfer appropriately.  If we are going to say that the 10x higher risk is the worst case scenario, where there are no babies in the hospital numbers who should have been in the home numbers, that would only make sense if no home birth midwife was able to correctly identify fetal distress and transfer.  I mean, to get to an Apgar of 0 at 5 minutes, you're talking about serious and prolonged fetal compromise, not a brief cord compression in late 2nd stage.  If we say that the midwives who did not transfer appropriately or who had a serious, s*** hits the fan scenario with no real time to respond or get to higher levels of care were in the minority, how many people should have been in the home birth group who weren't?  Were there 5 times as many midwives who transferred as who didn't?  All I need is 20 babies in the entire US in the entirety of the period of time covered in this study miscategorized and we're looking at a 13x higher relative risk home, midwife vs hospital, MD and a 23x higher relative risk home, midwife vs hospital, midwife.

 

The one real weakness that I can see is that it is unclear to me that we are talking about vertex presentation.  These are singleton, full term, not low birth weight, but we don't know if these kids are vertex or breech as far as I can tell.  If that point could be clarified by the authors, it would be awesome.  I want to know how many of these cases are breech head entrapments.  But even if we make fully half of the extremely low Apgars due to breech, is a 5x-9x higher risk of profound fetal compromise low enough that it shouldn't be disclosed to women interested in home birth?

 

I would really love for Science and Sensibility or some of the other birth advocacy and education groups to look at this study and give their perspective.  All I'm hearing is silence, and the silence is damning.

post #55 of 129
Quote:
Originally Posted by fruitfulmomma View Post

 

It would be really helpful to know what data they are basing this assumption on. Personally, unless I needed to be induced because I was at high risk for infection myself, I would not go to the hospital to birth a child who had already died. I would want the utmost privacy for that time.

Fruitful, I might consider a home birth for a known stillbirth, but if the fetal demise is known prior to the onset of labor, no one will be taking any Apgars so they would not be recorded.  Anecdotally, in the full term home birth stillbirth stories that I've come across, most mothers did have induction of labor in the hospital.

post #56 of 129

Well, no they wouldn't be, though it would be possible for them to record it as a zero in the registry rather than leaving it blank, I suspect. But now I am actually kinda scratching my head because these records they were looking at were birth certificates of live births, right??? So no stillbirths should have been in any group. I thought stillborn babies didn't get a birth certificate. (A quick google search shows some states giving out a seperate stillbirth certificate.) So I am not sure why they brought it up.

post #57 of 129

I wonder how many of these births take place in a metro area. I can't imagine any circumstance in which I would ever be with a baby with a zero apgar at five minutes without already being in the middle of a transport to the hospital. Every midwife here is trained in neonatal resuscitation and 911 is called within 2 minutes if a baby is unresponsive. I haven't ever had this scenario happen, thank goodness. I think it is odd that the numbers are so high. I would think that with most CPMs working with low risk moms and babies, that we would have a better outcome. 

post #58 of 129
Thread Starter 
Quote:
Originally Posted by IdentityCrisisMama View Post


Pillowy, thanks for posting the entire study! There sure is a great deal to discuss both from the perspective of understanding HB but also from the perspective of how this info influences our choices as home birthers.

Unfortunately, I have to ask that you remove the study for mothering copyright guidelines. You may PM copies if you choose.

 

Will do! Everyone, I have the full study if you want to PM me. :)

post #59 of 129

Fruitful, there might be intrapartum stillbirths, ie a baby who died during the course of labor who was unable to be resuscitated (think sudden placental abruption in the home setting, like the placental abruption in TX talked about in Aquila's Birth Story), but it'd still be during labor and outcomes that bad should still get counted.  I think that is part of what they are arguing.

 

Homebirthing, that would be interesting data, and maybe part of making home birth safer in the United States means a hard and fast "you must be within 20-30 minutes of a hospital" rule.

 

I agree with the author's conclusions that this information needs to be presented to mothers who are interested in home birth, because it is too high a magnitude to be static.  There is something really going on here.  I don't think that a response to this has to mean "no one has home births ever again!!!111ELEVEN!!11!"  But it should involve a really close look at who is appropriate in a home birth setting, what the criteria are for transfer (I had an emergency newborn transport 3 hours after birth, and retrospectively our midwife dropped the ball in letting us stay home for 3 hours with a baby who very clearly wasn't coming around right, and that decision could easily have cost our baby her neurological condition.  But she never had that bad an apgar, even though she could have sustained neurological injury.)  Having seen data on first time moms having worse outcomes in home birth settings in several different studies now, if we are trying to offer evidence based care, are we at the point where that increased risk needs to be part of informed consent?

post #60 of 129

In theory being within 20-30 minutes for homebirth sounds great! In reality, a big part of the women who are served best by homebirth live in small rural communities and have many children. A lot of these women would end up birthing in the buggy on the way to the hospital. I really don't get how ANY midwife would be at home unassisted with a baby of an APGAR of zero outside of extreme circumstances like no phone reception or a complete lack of skill and or understanding that there is a baby that is basically dead and needs immediate help past what you can provide. 

 

While monitoring in labor and risking women out antepartum will cut down on these situations, sometimes something dramatic happens at the time of birth, like a shoulder dystocia. I can see needing to do a full resus after something like that. But again, we are calling 911 within two minutes and the average response time here in the Twin Cities is less than three minutes. During that time, we are breathing for and creating a heartbeat for a baby who would otherwise not have one. Again, I haven't ever been in a situation with a baby of an APGAR of zero at one minute, much less five minutes. That sounds truly terrifying, regardless of where the baby was born. 

 

As far as things like twins, breech and VBAC, my state supports the right to birth all of these babies at home. I attend many VBAC's at home, and have attended three di/di twins and birthed my own di/di twins at home. The only option in our state is to have a surgical birth in the hospital or birth at home for breech, which is a recent change when our breech OB lost the right to catch at the local hospital. I think that is incredibly unfortunate because it shouldn't be the only option given to mama's. 

 

I don't get it. We work so hard as midwives to help healthy mama's and healthy babies stay at home. It should be safe across the board. We shouldn't have to have oversight by an OB-GYN, in my opinion. But we do need to have some form of oversight and guidelines (we do here) in order to create the best case scenario for women in the childbearing year. I don't believe birth is a medical event. I do believe in traditional midwifery and that most often less in more. However, if something goes horribly wrong, I am hired to do everything in my power to keep a mother and her baby alive. That is my job. That is why I am trained. 

 

Sarah 

New Posts  All Forums:Forum Nav:
  Return Home
  Back to Forum: Homebirth
Mothering › Mothering Forums › Pregnancy and Birth › Birth and Beyond › Homebirth › Apgar Score of Zero at Five Minutes