NICU RN questioning how midwives handle emergencies

[WoodlandFairytale]

Hello!

My former NICU RN, current neonatal RN mother has been asking me a lot of questions about homebirth lately. She understands why people do it (she has many horror stories about OBs - she works in a very old fashioned hospital), but her main problem with it is the 'what if' situations in which fatalities can occur. This is what she just said to me:

"Maybe there are just a handful of bad outcomes in the big picture but you have to ask yourself if you want to take that chance. If something happened - even if it wasn't necessarily a result of your decision - you could never know for sure - and you would have to live with that. I know you - you're a lot like me and you would never forgive yourself. there are a lot of things that can go wrong at the last minute which could mean the difference between life and death (literally) for both you and your baby. Even a few minutes delay could make a huge difference in the outcome. Things like prolapsed cord, meconium aspiration, shoulder dystocia, tight nuchal cord, abruption, uncontrolled bleeding, etc - the list goes on and on. Again - things like this don't happen very frequently but they do happen - and they CAN happen to you."

My question to you guys is - what DO midwives do in these situations? Is there a source of info on the web somewhere that I can find this? She is just convinced that midwives can't handle emergencies and I'd like to give her some info. Since she is a medical professional, vague answers don't really do it for her, she wants specifics. So far she has been open to any info I can give her about natural childbirth, why women wouldn't want to give birth in the hospital, etc. so I'm hoping that she might be more open to homebirth if I can provide her with responses to her questions. She is midwife friendly - she has worked with many in her 20+ years at the hospital and has positive views of them - so that helps.

I know about the Gaskin maneuver for SD and the somersault maneuver for tight nuchal cord (though I'm aware that this often resolves itself as the baby is born), and the all-fours, butt-in-the-air, midwife sometimes holding the baby up off the cord until arrival at a hospital for prolapse. I know that midwives carry something they inject into women who hemorrhage (can't remember the name), and some midwives use Shepherd's Purse.

I haven't told her any of these things yet, just making a list. Do you guys have any more specifics, or can you point me to a website? I've done research online but haven't found much.

Thanks!

[Malga]

Well, I'm not an expert, but I can give you some information that I know. I work in a rural hospital right now (no NICU and anasthesiology is not there 24 hours a day every day-- in many smaller hospitals they aren't, no OB residents in house, but we do 1500 births a year) and people just don't understand that in the middle of the night, having your baby at a hospital like this is probably less safe than having the baby at home with a competent midwife. Many midwives could prep an OR ahead of time on the way to the hospital in an emergency and have a baby out within the 30 min-decision-to-incision time frame (same amount hospitals are supposed to be able to do).

Even a few minutes delay could make a huge difference in the outcome

In these scenarios babies can die in the hospital too (and moms), it just doesn't get the publicity that it does with a homebirth. For example, with a shoulder dystocia most midwives know all the same maneuvers an OB would do. But, if nothing works the baby might die-- regardless if you are in the hospital or not (I think the only manuever a midiwife couldn't do are the last resort manuevers like cutting the symphsis pubic or the one where you push the baby back and do a stat c-section, but if your to that point you probably aren't going to have good results regardless of where you are).

meconium aspiration

In my experience in the hospital-- you would be better off with the midwives I've worked with than be at a rural hospital in the middle of the night with this. Midwives are trained the same as OBs and nurses in how to deal with this situation and are more willing to step in (unlike the nurses I work with)-- if the baby isn't vigorous than the trachea is suctioned before resuscitating the baby. The midwives I have worked with carry or have these tools on hand just like the hospital and can intubate if needed. Then you do the same thing as you would in a smaller hospital-- transfer baby to a NICU.

tight nuchal cord

This happens often-- whether in the hospital or at home. If they have too, midwives will cut the cord just like an OB would.

uncontrolled bleeding

Postpartum Hemmorhage is treated the same. The midwives I have worked with carry all the same drugs (Pitocin, Methergine, Misoprostol). If those don't work the women would be transferred to the hospital for a hysterectomy (or other last resort treatment). Same treatment in the hospital. Of course, this would be less likely to happen at home because midwives don't do inductions and Pit people for days which leads to PPH.

Things like abruption or rupture are disasterous wherever you are. Even if someone ruptures in the hospital the baby often dies, but again, the hospital doesn't get the publicity the midwives do. But, I do believe they are less likely to happen at home because midwives are not inducing or augmenting labors with unnatural means. A lot of "emergencies" are avoided with the care the midwives provide.

NICU RNs see the worst of the worst, so I understand why they think like the do. I also see why OBs think like they do-- its their reality if you know what I mean. Its how they were trained (and the person before them trained) and its what they are immersed in. They don't know any other way. But, having worked in both areas (the medical- hospital model, birth centers and homebirth) I would be afraid to birth in the hospital if I was having a normal pregnancy-- you are just introducing more risk and more interventions.

[MsBlack]

This is a really big question...really, really big. Rather than trying to answer it, I'm going to suggest that this woman find some of the texts written for hbmws. She might be able to find a local mw who would loan these books to her. It would take a lot of time to answer all of her questions, especially if she wants specifics--I would not want to give her that much of my time for free, but would be most happy to help her spend her own time researching!

I think what I would tell her is that homebirth is very different from hospital birth (most of the time, with most hb pracitioners), and that yes, hbmws do have protocols for every sign, symptom and emergency that could arise. I would then invite her to come look at my books (or some mw's books) so she could explore this for herself, as thoroughly as she wanted to, on her own time. I'd probably also invite her to do some research on the safety of planned homebirth worldwide (and maybe provide some links), so that even apart from knowing our protocols and skills, she could reassure herself that homebirth actually has been proven safe.

Because of her great experience-and-knowledge base as an RN, and also because of her medical orientation, I doubt you will be able to satisfactorily answer her questions. But she can certainly get her questions answered if she likes, by investing her time and academic energy into a search of texts used by hbmws.

good luck!

[WoodlandFairytale]

Originally Posted by MsBlack

Because of her great experience-and-knowledge base as an RN, and also because of her medical orientation, I doubt you will be able to satisfactorily answer her questions. But she can certainly get her questions answered if she likes, by investing her time and academic energy into a search of texts used by hbmws.

good luck!

Thanks for your response - unfortunately I'm pretty sure she's not going to put that much energy into it. I am going to try to get my hands on a hbmw text so I can read up on it and have a discussion with her about it. I'm not too concerned about convincing her in order to feel okay about what I choose to do - I'm just hoping that, since she is somewhat open to hearing responses to her questions, it might help to allay some of her fears so she is less annoying once I get pregnant.

I understand it's a huge question! I just hoped there might be a link to some website out there that went into it.

[WoodlandFairytale]

Originally Posted by Malga

Well, I'm not an expert, but I can give you some information that I know. I work in a rural hospital right now (no NICU and anasthesiology is not there 24 hours a day every day-- in many smaller hospitals they aren't, no OB residents in house, but we do 1500 births a year) and people just don't understand that in the middle of the night, having your baby at a hospital like this is probably less safe than having the baby at home with a competent midwife. Many midwives could prep an OR ahead of time on the way to the hospital in an emergency and have a baby out within the 30 min-decision-to-incision time frame (same amount hospitals are supposed to be able to do).

Thanks so much for this detailed response. I really appreciate all your answers! I guess I am just going to have to continue researching it myself so I can respond to her questions when we discuss it.

[momma earthical]

Go to http://www.minnesotamidwivesguild.com/ , click on Standards of care on the left. It won't have the level of technical detail you are looking for but it might help you in some way.

Good luck!

[momileigh]

An entry-level homebirth midwifery text that is enjoyable to read is Heart & Hands by Elizabeth Davis.

[tinyshoes]

Originally Posted by WoodlandFairytale

...Things like prolapsed cord, meconium aspiration...

What would an OB, an RN, or any hospital staff do until the mom was in the OR suite getting her c-section? In a hospital setting, who is the first person to identify the prolapsed cord? It does not go: 1# prolapsed cord discovered, 2# baby instantationously saved by virtue of being in hospital building.

It might be that the same standard of care (butt-in-the-air, transvaginal pressure applied to fetal head to keep it off the cord) is the same technique used moving from labor room to OR as home to OR. (Probably, women shouldn't give birth in any other place than an operating room, hunh? oh wait...we already did that in the 50s, 60s, and 70s. and according to the citation below, hospitals allowing moms to labor and birth in the same room has not resulted in more deaths form prolapsed cords.)

from UpToDate.com

The incidence of UCP [umbilical cord prolapse] ranges from 0.14 to 0.62 percent and has not changed in years.
...
perinatal mortality related to UCP, which was as high as 375 per 1000 births in the early 1900s, has fallen to between 36 and 162 per 1000 births within the past few decades [2]. This decline is likely secondary to significant improvements in neonatal intensive care and immediate delivery by cesarean birth once cord prolapse is diagnosed.
...
Obstetrical interventions — Obstetrical intervention may result in iatrogenic UCP.

http://patients.uptodate.com/topic.a...=labordel/2191

The resource cited above also offers a tidy list of risk factors for UCP....which include risk factors that would cause a low-risk homebirthing woman to "risk out" and no longer be eligible for a midwife-attended homebirth (i.e., premature baby.) Also, the first risk factor listed for UCP is fetal malpresentation, and any OB or CNM or homebirth midwife will tell you which practitioner knows best the location of the fetus in the womb: it is always the hands-on practitioner, who is most frequently, a midwife. The know where the baby is WITHOUT ultrasound; they can use their hands!

As for meconium aspiration, I find it curious that a NICU RN would not be aware of the latest research that identifies meconium aspiration syndrom (MAS) as a condition that develops in utero, and is not prevented by suctioning at birth (if indeed this is the part of meconium aspiration that your mom is referring to.)

Perhaps asking her some questions will invite some reflection on birth and babies in general:

Ask about GBS infections in newborns, and the prevalence of other neonatal infections (esp. E. coli) in the newborn population as a result of routine GBS testing of pregnant women and the resulting widespread use of antibiotics.

Ask her about the c-section born babies and the prevalence of breathing issues with that population?

Ask her about common procedures done to newborns and how she feels about them--does she like how OBs vacuum babies out?

Does she have firsthand experience with a baby nicked by a scalpel during a cesarean? (That's a more common occurance than some of the horrors your mother has cited...the cord prolapse rate is 0.14% to 0.62% as cited above, and babies getting cut is 3%.)

from ACOG's journal Obstetrics and Gynocology 2006

The most commonly identified injury at cesarean delivery is fetal laceration, and its incidence has been reported to be as high as 3%.

from
http://www.greenjournal.org/cgi/content/full/108/4/885

Maybe a mainstream book that critiques modern obstetrical care could offer some insight for your ma:

Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First by Marsden Wagner
http://www.amazon.com/Born-USA-Broke...4987407&sr=8-1

Even with the magic that can be done in the NICU, the US is still a shamefully unsafe place to have a baby, when compared to other industrialized nations. I think your mother is very wise to share her concerns and feelings with you, and to explore the ACTUAL ANSWERS to those concerns.

[tanyalynn]

Alice, I'm not a birthing professional, so I feel really awkward answering, but I'm going to be having a similar conversation with my SIL (current NICU nurse) whenever I'm next pregnant (despite both my kids being born out of hospital!). I think there's a big assumption that underlies the questions we get, and that is that if anything goes wrong with a homebirth, it is _because_ it is a homebirth, but if anything goes wrong with a hospital birth, it is _despite_ being in a hospital. I am struggling with how to explain to my SIL that the very restrictions that hospitals place on laboring women, the monitoring, movement restrictions, timelines, breaking of waters, etc, can contribute to difficult situations. Anyway, not sure if that really helps or not, but to me that is the biggest gap in understanding between those comfortable with homebirth and those not.

[BugMacGee]

[Ask about GBS infections in newborns, and the prevalence of other neonatal infections (esp. E. coli) in the newborn population as a result of routine GBS testing of pregnant women and the resulting widespread use of antibiotics.

Actually tinyshoes, this is really only true for the very low birthweight population due to repeated antibiotic exposure in utero (infection being suspected in PTL)

Carry on.

[WoodlandFairytale]

Thanks for your reply, tinyshoes.

I live 7 minutes from a level III hospital - 5 or less, if you drive fast. I guess my biggest question in attempting to respond to my mother is, would a CNM with a backup OB at the hospital (she has hospital privileges) be able to get a stat c-section or other emergency procedure required in case of emergency, anywhere near as quickly when transferring as she would be able to if we were in the hospital?

My mom has warned me to not let an OB near me with foreceps or a vacuum extractor, she's seen babies with damage as a result. She definitely does not want me to get a c-section unless it's absolutely required. She is somewhat aware of the fact that hospital interventions can cause more problems, and she is happy that I'm educating myself about what can go wrong and what would be done in a hospital setting as a result. Her number one problem with homebirth is those situations in which something goes wrong and a few minutes difference between trasferring from home or being at the hospital already could mean life or death (or brain damage, paralysis, etc.)

[rajahkat]

"I live 7 minutes from a level III hospital - 5 or less, if you drive fast. I guess my biggest question in attempting to respond to my mother is, would a CNM with a backup OB at the hospital (she has hospital privileges) be able to get a stat c-section or other emergency procedure required in case of emergency, anywhere near as quickly when transferring as she would be able to if we were in the hospital?"

I would say in that situation (so close to hospital, provider privledges at hospital) the answer is almost definitely yes. But your CNM should be able to give you more specifics. Come to think of it, why don't you let your CNM talk to your mom. She'll likely win her right over and then you won't have to stress about it.

[Defenestrator]

Originally Posted by WoodlandFairytale

Thanks for your reply, tinyshoes.

I live 7 minutes from a level III hospital - 5 or less, if you drive fast. I guess my biggest question in attempting to respond to my mother is, would a CNM with a backup OB at the hospital (she has hospital privileges) be able to get a stat c-section or other emergency procedure required in case of emergency, anywhere near as quickly when transferring as she would be able to if we were in the hospital?

My mom has warned me to not let an OB near me with foreceps or a vacuum extractor, she's seen babies with damage as a result. She definitely does not want me to get a c-section unless it's absolutely required. She is somewhat aware of the fact that hospital interventions can cause more problems, and she is happy that I'm educating myself about what can go wrong and what would be done in a hospital setting as a result. Her number one problem with homebirth is those situations in which something goes wrong and a few minutes difference between trasferring from home or being at the hospital already could mean life or death (or brain damage, paralysis, etc.)

I want to offer up a story as a mom, not as a midwife -- when I was preparing to homebirth and living in Illinois, my mom absolutely freaked. She called me one day and before even saying hello said, "You and the baby are both going to die!" She continued to be very worried throughout my pregnancy, even after meeting my midwives and having me move into her house (where, theoretically, she could protect me from my own foolishness).

I had an uneventful birth -- short labor, no bleeding, no complications for the baby. When he developed pathological jaundice, the midwives helped me get the care I needed and we treated him at home. It wasn't until later that we were able to have a rational conversation about the whole thing.

The thing that I was finally able to convince her of was the fact that I actually had much better access to technology than what she did when she gave birth. I gave birth at home with a trained midwife and a trained apprentice. I got excellent care, with frequent visits right after the birth to check up on me. If I had an emergency, a teaching hospital with 24 hour anesthesia and every specialist in the world would be available to me after a 10 minute drive. The same hospital had a level IV NICU.

In contrast, she gave birth in a small college town in Northern Michigan. There was no anesthesiologist in house, no doctor in house -- she arrived to the hospital at 9 cms and was held down by the nurses and forced not to push for 30 minutes while the doctor arrived. There was no special care nursery at all, let alone a NICU. There still isn't a Level IV NICU within an 8 hour drive or so of the town where she lived -- and were they even using helicopters for transports in 1970? Certainly if her baby needed sophisticated care it might take hours for her to get it. A doctor friend of mine who works on maternal mortality says that some small community hospitals don't even stock blood for transfusions.

Just because some hospitals can respond instantly to emergencies doesn't mean that they all can. And sometimes their responses are not evidence-based or even competent. I saw a shoulder dystocia in the hospital where they only tried one maneuver, the McRoberts position with super-pubic pressure, again and again and again, using more and more force, for nearly 4 minutes. The baby was born without injury, but needed a full resuscitation. I have also seen aggressive suctioning for meconinum on a baby that was vigorous and fine. Homebirth midwives make mistakes, but at least you can have some sense of who you are dealing with. When you go into the hospital, nearly everyone who is part of your birth is a stranger.

[cottonwood]

She's absolutely right -- there are some situations in which not having a certain type of medical care immediately available could result in death/injury, and not all midwives -- nor all doctors, nor all hospitals -- have it all. But does that justify putting birth at increased risk for developing complications? It depends on the actual incidence of these things. How often do complications occur naturally? How often to they occur iatrogenically or environmentally? For instance, what is the incidence of shoulder dystocia in fully spontaneous second stage with instinctive positioning? It also depends on the individual situation, for instance, are you at risk for cord prolapse if the baby's head is well engaged before labor starts?

Women who have chosen homebirth aren't discounting risk -- every single choice you make is going to have risks inherent to it. They've just come to the conclusion that homebirth for them poses less overall risk.

[pamamidwife]

I'm wondering why, if your mom won't read a book or do research, this sort of conversation will sway her or ease her fears?

Perhaps the easiest thing to do is to arrange for her to come to a couple prenatal visits with you. I find that when grandparents are invited, questions are asked, etc. It's very informative on both ends.

If she's not interested in that, I would just politely end the conversation when she brings up the topic. It's not your job to convince her that you're making the best choice for you.

[WoodlandFairytale]

Originally Posted by pamamidwife

I'm wondering why, if your mom won't read a book or do research, this sort of conversation will sway her or ease her fears?

Perhaps the easiest thing to do is to arrange for her to come to a couple prenatal visits with you. I find that when grandparents are invited, questions are asked, etc. It's very informative on both ends.

If she's not interested in that, I would just politely end the conversation when she brings up the topic. It's not your job to convince her that you're making the best choice for you.

Thanks for your response. I read your blog and value your opinion.

My mother is convinced that any books I could offer her to read are completely biased. She will undoubtedly think that any information via face-to-face discussion I give her is biased as well, but I'd like to feel like I at least tried.

Thanks to fourlittlebirds, defenestrator & rajahkat, too!

defenestrator - good points. My mom gave birth to me in a small community hospital; she was in painful labor (in the lithotomy position, with no one around to comfort her aside from my dad, who was clueless) for over 24 hours before being given a c-section for failure to progress. For her next 2 babies, she chose elective c-section because she was afraid of experiencing that again.

[Kitten]

pamamidwife- that was my thought exactly. If she doesn't want to invest any time in actual research, she isn't really interested in learning and just wants to have a "debate" (meaning, tell you that you are foolish and unable to make decisions for yourself.) OP if I were you I would just change the subject every time it comes up.

[liseux]

I had a true shoulder dystocia at home with totally instinctive pushing & positioning. My mw kept her cool throughout. It was eventually fatal to my baby and I spent 7 weeks in the NICU with him with many nurses asking me questions about hb or blaming me for choosing hb. Finally, after spending time with the same nurses day after day, a few of them looked into s.d. more & realized it can be just as bad in the hospital, if not worse. I spent the first 3 years after that learning about s.d. & I have definitely come to the conclusion its not handled any better in the hospital.

A true s.d. is like a child choking, it either resolves or it doesn't. One difference is that at home you have a mother who is not epidural & bed bound & is more likely to get her body into the various positions and maneuvers. I know examples of doctors who panicked and mw's who stayed very calm. The only thing that a dr. can do that a mw can't in a true s.d is the Zavanelli manuever (c/s with head pushed back in) I think somebody above mentioned that. Nobody does symphysiotomy. And the stats on the Zavanelli manuver are horrible. The main thing that can free a stuck baby (if Gaskin truly does not work ) is breaking the clavicle. Which is not very easy to do.

Living with a loss like this is extremely hard...but it comes back to intentions. As a mom you have the best intentions when choosing hb. I don't have any proof that we would have had a better outcome in the hospital. It took some good talk therapy & time, but I can speak to "living with yourself". Some bad things still happen, they are rare, but being at home is still very safe and most of the time, the most gentle and natural beginning.

Its hard to say with the other emergencies, but to me the 3 big ones are preeclampsia, (usually has warning--if it goes straight to eclampsia --the hospital is needed urgently) Shoulder dystocia(no warning, probably has a better outcome at home) and a huge pp bleed.

[WoodlandFairytale]

liseaux-

Thank you so much for your personal account. I'm so sorry for your loss

It means a lot to hear from a mom who's btdt. I'm going to look up the stats on the Zavanelli maneuver... after all the research I've done into the subject, I'm absolutely convinced that homebirth is the safest option (assuming I don't have a high risk pregnancy).

[homewithtwinsmama]

I know you - you're a lot like me and you would never forgive yourself. there are a lot of things that can go wrong at the last minute which could mean the difference between life and death (literally) for both you and your baby. Even a few minutes delay could make a huge difference in the outcome. Things like prolapsed cord, meconium aspiration
, shoulder dystocia, tight nuchal cord, abruption, uncontrolled bleeding, etc - the list goes on and on. Again - things like this don't happen very frequently but they do happen - and they CAN happen to you."

My question to you guys is - what DO midwives do in these situations? Is there a source of info on the web somewhere that I can find this? She is just convinced that midwives can't handle emergencies and I'd like to give her some info. Since she is a medical professional, vague answers don't really do it for her, she wants specifics. So far she has been open to any info I can give her about natural childbirth, why women wouldn't want to give birth in the hospital, etc. so I'm hoping that she might be more open to homebirth if I can provide her with responses to her questions. She is midwife friendly - she has worked with many in her 20+ years at the hospital and has positive views of them - so that helps.

I know about the Gaskin maneuver for SD and the somersault maneuver for tight nuchal cord (though I'm aware that this often resolves itself as the baby is born), and the all-fours, butt-in-the-air, midwife sometimes holding the baby up off the cord until arrival at a hospital for prolapse. I know that midwives carry something they inject into women who hemorrhage (can't remember the name), and some midwives use Shepherd's Purse.

My midwife is super duper experienced direct entry midwife with a CPM certification (that is illegal in our state sadly). I have worked with her a long time and she has had all of this stuff. Here is just some of the experiences she and I have had.

Last night we had a precipitous birth. Mama had been going to hosp. midwives but she has silent dilation and then started pushing. I had no time to get her to the hosp. but my midwife lived ten minutes away and was home so I called her to help me. We had shoulder dystocia complicated by the elbow wrapped behind the head. Since mama is unmedicated we threw her into Gaskin and rotated the shoulder, got the arm out, which released the posterior shoulder and then were able to get baby out. Baby needed just a couple quick puffs and some stimulation to come around. Hosp. would have likely been a giant episiotomy and McRoberts(shown to be more dangerous) or shove baby back up and do cesarean (really dangerous, but I know where that was done in MD once and mother almost died from surgical complications).

Cord Prolapse happened at a homebirth a couple years back. Mama's water broke with such force at ten centimeters that cord swept past head. Midwife checked FHT as soon as water broke and it was deceling. She did vaginal exam and got handful of cord. Had dad call 911 and put her on speaker. Explained to dispatch what was happening and that they needed to call the closest hospital (five minutes away) to have OR prepped. As this was happening she flipped mama to knee chest position, put her hands inside to hold baby's head off cord and put doppler under belly with her other hand so she could listen. As long as she kept her hand in pushing head tones were low normal (120-130). Ambulance came and they transported with midwife keeping hand inside and monitoring. Mama wheeled on gurney this way into OR. Surgical team prepped mama and put her under general then asked midwife to pull hand out and they cut. From home to surgery was under 25 minutes. Better decision to incision time than often happens IN hospital emergencies (this has been studed that DTI time is an average of 45 minutes) . I once had an emergency with a doula client where it took three hours to get the mama her cesarean. I was very upset and frustrated cause baby was in the 70-90 FHTs that whole time and spent 12 days in NICU in my opinion because of the delay!

Abruption - pretty damn rare in healthy mothers anyway, but usually you are going to see abnormal amounts of bleeding during the labor and any hb midwife worth her salt is going to transport for bleeding as well as for meconium that is more than light. If they stay home with light mec and good FHTs then they would use the Delee to suction out the baby before it breathes just like you see at hospitals. Studies have shown that mec aspiration syndrome is NOT preventable by suctioning on perineum and all that is done in hosp. because usually the aspiration has happened before birth. If the baby is not breathing well in any way they would provide oxygen support and transport immediately. I have done a few light mec homebirths and suctioning and bulbing was all that was done and baby was fine. More than light mec we ALWAYS transport.

Bleeding after birth - First our mamas are heathier, many taking Red Raspberry during pregnancy to tone and strengthen uterus, Alfalfa which reduces hemmorhage (first discovered in horses and adopted by midwives in the form of liquid chlorophyll supplement taken in pregnancy). My midwife carries pitocin and methergen. Last night we had a placenta that was taking it own sweet time. We had a separation gush, but it was still not all the way off. We gave Angelica tincture to separate, Labor tincture to give the contractions a little more umph and mama pushed it out. We had pit ready if she bled more. We would leave a methergen tablet or two with her once we were ready to leave should the bleeding start up and soak an overnight bad in 1/2 an hour.

We give shepherds purse in a cup of tea with lots of milk and honey after the placenta to aid in clamping down on normal mamas who did not bleed excessively. Of course all homebirth mamas are initiating breastfeeding immediately unlike in hosp where they throw them in the french fry warmer and baby often doesn't get near the breast to provide the biologically designed stim to the nipples to release natural oxytocin to prevent bleeding. Because it is so almightly important to give ointment in the eyes and Vit K and strap that ID bracelet on and on and on and on...She would get an IV to expand volume if the loss was large. She would be transported if we felt IV would not be enough and she would need transfusion. We would obviously stay with her longer at birth if we felt she was not stable from blood loss. Postpartum she would go back on liquid chlorophyll and Floradix herbal iron supplements to build the blood.

The main thing is that she knows that babies don't all live. Plenty of babies die in the hospital regardless of what you do. You will never prevent all deaths in any settting. Stillbirths(I had a client on continuous monitoring in the hosp. whose baby just went still -bam - with no warning, you will occasionally lose a baby due to a complication in the hospital as I did) just happen and 60% of the time a cause can't be identified. The risks of homebirth in healthy populations is as low or lower than in hospitals in every single study out there except the lousy Oregon one done by a bunch of OBs with an ax to grind (the rates of women choosing midwives in Oregon is very high and is a lot of competition for OBs there) who included unassisted homebirths and births before 35 weeks that no respectable midwife would have been any where near. Vermont has the highest rate of homebirth in USA per capita as well as the lowest maternal and infant morbidity and mortality.

Lastly, Netherlands and Norway have the BEST maternal and infant morbidity and mortality rates. They also have 25% or more of all babies being born at home. If homebirth is so dangerous they could not possibly lead the world with these stats. Also you should look for the NARM study from two years ago that was of 5000 American homebirths. It was published in the British Journal of Medicine. Hope that helps.