Help me understand risks and solutions of homebirth - Mothering Forums

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#1 of 30 Old 12-21-2010, 07:37 AM - Thread Starter
 
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I had a hospital birth with my first baby, and it turned out to be an awful experience.

 

I resent the fear surrounding birth in this country, and I have read most of the birthing books.  However, when thinking about the “other” side, I continuously read things about how an emergency can be imminent and immediate transfer can not get a patient to a doctor in time.

 

So, what are the events in a birth that are deemed a sudden emergency?  What should a qualified midwife do to control for these?  Can we start a list?

 

I can begin:

 

1) Placenta pervia

2) Prolapsed cord

 

What else?  How would an experienced midwife handle these situations?

 

Am I looking at things wrong?  Should I not approach it like this?


Me: New mama to DD born 11/17/2009. We And:
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#2 of 30 Old 12-21-2010, 08:18 AM
 
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This is exactly the way I look at it and I've been compiling a list in my head.

 

Placenta previa would almost certainly be diagnosed before labor (and it is an absolute indication for a c-section), so I don't think that would be on the list as a sudden emergency.

 

1. Cord prolapse.  solution: EMS called, get on hands and knees with butt in the air, midwife or someone holds baby's head up manually to keep pressure off the cord, you ride in the ambulance that way and emergency section at the hospital.

 

2.  Placental abruption.  solution: emergency transport to hospital, emergency c-section.

 

3.  Shoulder dystocia.  solution: Gaskin maneuver, sometimes breaking baby's clavicle to get her/him out.  This one is time-sensitive enough that it has to be handled at home, and midwives are trained to handle it.

 

4.  Head entrapment (breech).

 

5.  Uterine rupture.  solution: emergency transport to hospital, emergency c-section and possible hysterectomy for mother.

 

6.  Baby not breathing after birth.  (I have heard a story of this happening for no apparent reason and the baby died).

 

7.  Placenta accreta/increta/percreta. 

 

8.  Postpartum hemorrhage.  solutions: pitocin shot, shepherd's purse to manage at home; if bad enough, emergency transport to hospital and pitocin IV and possible blood transfusion.

 

That's just a partial list from my admittedly limited knowledge.  I'm sure a midwife or midwifery student could add to the list.


SAHM to Bird (6/07) and Bear (7/09), and now enjoying our newest additionbabyboy.gif, born June 1, 2011!  bfinfant.giffamilybed1.gifsigncirc1.gifcd.gif

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#3 of 30 Old 12-21-2010, 08:32 AM
 
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Originally Posted by msmiranda View Post

This is exactly the way I look at it and I've been compiling a list in my head.

 

Placenta previa would almost certainly be diagnosed before labor (and it is an absolute indication for a c-section), so I don't think that would be on the list as a sudden emergency.

 

1. Cord prolapse.  solution: EMS called, get on hands and knees with butt in the air, midwife or someone holds baby's head up manually to keep pressure off the cord, you ride in the ambulance that way and emergency section at the hospital.

 

2.  Placental abruption.  solution: emergency transport to hospital, emergency c-section.

 

3.  Shoulder dystocia.  solution: Gaskin maneuver, sometimes breaking baby's clavicle to get her/him out.  This one is time-sensitive enough that it has to be handled at home, and midwives are trained to handle it.

 

4.  Head entrapment (breech). i have a friend whose baby died of this.  It is much more common in mishandled breech births (where a careprovider manipulating, pulling on or sometimes even just touching the baby which causes the baby to unflex its head), so a planned breech HB will very very rarely result in this.  For an unplanned breech the reaction will vary from MW to MW - ask ahead of time.  If the MW is happy and comfortable delivering breeches she will most likely just get you into a good position with an open pelvis and NOT touch the baby until it is born.  A less comfortable MW or a mama that wants it can call an ambulance before the baby is emerging (as soon as the breech is visible).

 

5.  Uterine rupture.  solution: emergency transport to hospital, emergency c-section and possible hysterectomy for mother.

 

6.  Baby not breathing after birth.  (I have heard a story of this happening for no apparent reason and the baby died).  My MW was fully trained in neonatal resus and had all the requisite equipment with her.  My DD1 did need suction and oxygen to get going well and it was done very smoothly - baby was taken to window to observe skin tone in good light as they suctioned and gave some oxygen with mask, once she was beginning to stir she was put onto my chest to help her regulate her systems and i held the oxygen tube (with the mask off) under her face so it was blowing against her nose and mouth.  Her apgars were 9, 7 and 10, i think the premature cutting of her cord was what caused the dip.

 

7.  Placenta accreta/increta/percreta. They would call EMS and transfer for PPH/non-delivered placenta and it would be dx and dealt with in the hospital.

 

8.  Postpartum hemorrhage.  solutions: pitocin shot, shepherd's purse to manage at home; if bad enough, emergency transport to hospital and pitocin IV and possible blood transfusion.

 

That's just a partial list from my admittedly limited knowledge.  I'm sure a midwife or midwifery student could add to the list.



I'm not a midwife.  I had the same questions and did the same research when i was expecting #1.  I filled out a little with bolded text.

 

Something of what comforted me was finding out how common these things actually are, and also what would happen if i was already in the hospital.  At my local hospital the average time taken from dx of need to birth of an emergent c-section is 45mins.  That is not to say that some babies don't need and get faster treatment, but that the majority of c-sections those doctors are doing, the most COMMON reasons for csections, were not at all deadly situations.  If you have a MW who can deliver in hospital then it's likely they can be setting up theatre/getting team assembled while you transfer.

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#4 of 30 Old 12-21-2010, 11:01 AM
 
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let me get back to you on this.. I'm actually planning on having a discussion with my midwife today about the risks and such.

 

yes there are some risks asscoiated with having a homebirth but there are also a number of risks asscoiated with being in the hospital. i to am planning my first homebirth after having two realivley easy hospital births.

 

A properly equipped midwife will have on hand the nesscary tools for many things that a hopsital will have for emergency. In some more remote hospitals they will have pretty much what they would have.

 


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#5 of 30 Old 12-21-2010, 11:41 AM
 
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I have nothing to add, but wanted to say as someone who's also planning my first HB I am loving this thread. I admittedly don't know many of the problem/solution scenarios yet so this is great for me. Thank you!  =)


~Christy, wife to M and mother to M and A, expecting baby #3 in May 2011 Planning our first HBAC!
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#6 of 30 Old 12-21-2010, 12:18 PM
 
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I just wanted to add that the research shows that a key element in the safety of homebirth is that the midwife is well integrated into the health system. So I would add in several of the emergencies listed above, that the midwife would call ahead to the hospital to have the OR prepped and the surgeon present. This cuts the delay significantly and is a key condition for me choosing homebirth. In my case, this means I chose a homebirth CNM who collaborates with docs/hospitals to make this link smooth. The awesome homebirth study results in Canada and the Netherlands have a lot to do with how well midwives are integrated into the system overall. And it may also be part of the reason that US homebirth stats look pretty terrible by comparison, since many midwives lack this connection and have trouble facilitating a smooth transfer.


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#7 of 30 Old 12-21-2010, 02:00 PM
 
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Quote:
Originally Posted by Mama Metis View Post

I just wanted to add that the research shows that a key element in the safety of homebirth is that the midwife is well integrated into the health system. So I would add in several of the emergencies listed above, that the midwife would call ahead to the hospital to have the OR prepped and the surgeon present. This cuts the delay significantly and is a key condition for me choosing homebirth. In my case, this means I chose a homebirth CNM who collaborates with docs/hospitals to make this link smooth. The awesome homebirth study results in Canada and the Netherlands have a lot to do with how well midwives are integrated into the system overall. And it may also be part of the reason that US homebirth stats look pretty terrible by comparison, since many midwives lack this connection and have trouble facilitating a smooth transfer.



What do you do in my position?  There are no doctor/midwife relationships where I live.  A doctor won't even see me during pregnancy because I'm planning a homebirth.  There is no support whatsoever.  All the CNMs deliver in hospital only.  I know because I called every one for insurance purposes.  I look for a midwife I trust implicitly and assume that upon calling the hospital in an emergency, they listen and believe what we tell them.

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#8 of 30 Old 12-21-2010, 08:00 PM
 
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Singfourever, if it were me, I'd look for a doctor or a CNM that I could trust to work with in the hospital.    The more I've looked at how long it takes to transfer, the more I am convinced that situations like placental abruption just can not end well if they occur at home.  My experience is that I developed good relationships with my HCPs during pregnancy, and that those relationships made it easier for me to navigate the hospital system successfully, *even when the HCPs I'd dealt with during pregnancy weren't present.* 

 

The less contact you have with the hospital system before labor begins, the fewer options you wind up having if you have to go there in an emergency.  Before labor, you can say what you want, and why, and find out what the policies are, and how and where they can be flexed.  When you come in laboring, and they have to take you on with no prior knowledge, they have to assume the worst on pretty much every front, and you have much less room to maneuver.

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Quote:
Originally Posted by MeepyCat View Post The more I've looked at how long it takes to transfer, the more I am convinced that situations like placental abruption just can not end well if they occur at home.


I fully agree with this statement.  It seems that in a lot of discussions on homebirth complications the answer "transfer" is inadequate.  When you figure in the time it takes to make the call, an ambulance to arrive, transport time, plus the time to get into the hospital, see the appropriate provider, get their assessment then treatment can be a substantial amount of time.  Whereas if you were in a hospital and had, for instance, a postpartum hemorrhage, they have drugs, blood, an OR, anesthesia, etc either on hand or on call, the response time is substantially shorter.

 

I think it is a good conversation to have and to fully understand the risk involved.  I think everyone should be able to choose if they have a homebirth or not, but I think that the risks have to be clearly stated and accepted by the mother before proceeding.  Just saying homebirth is "safe" is inadequate, and really does not provide informed consent as is advocated for so strongly on these boards.

 

Just my two cents :-)

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#10 of 30 Old 12-21-2010, 08:43 PM - Thread Starter
 
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Okay, so, I will  ask my questions regarding each of the complications brought up.  I would like to keep this thread as bias-free as possible- I really hope to get some answers and not speculation and commentary.

 

Quote:

1. Cord prolapse.  solution: EMS called, get on hands and knees with butt in the air, midwife or someone holds baby's head up manually to keep pressure off the cord, you ride in the ambulance that way and emergency section at the hospital.

1- How effective is it to get on hands and knees with the butt in the air?  Does that actually help stop the cord from coming out? 

2- How quickly does a transport to the hospital need to take place in order for a safe delivery?

3- What are the signs of cord prolapse?  At what point should a good midwife start to think of transport?

 

Quote:
2.  Placental abruption.  solution: emergency transport to hospital, emergency c-section.

1- What are the signs of a placental abruption?

2- When would a trained midwife know when to transport?

3- How quickly does a transport need to take place in order for a safe outcome?  How quickly does it happen in a hospital?

 

Quote:

3.  Shoulder dystocia.  solution: Gaskin maneuver, sometimes breaking baby's clavicle to get her/him out.  This one is time-sensitive enough that it has to be handled at home, and midwives are trained to handle it.

1- When I read Ina May Gaskin's book, she made it seem like her method was effective the vast, vast majority of the time.  Is this true?

2- How tragic are the effects?

3- How often does this occur and how is it handled in the hospital?

 

Quote:

4.  Head entrapment (breech). i have a friend whose baby died of this.  It is much more common in mishandled breech births (where a careprovider manipulating, pulling on or sometimes even just touching the baby which causes the baby to unflex its head), so a planned breech HB will very very rarely result in this.  For an unplanned breech the reaction will vary from MW to MW - ask ahead of time.  If the MW is happy and comfortable delivering breeches she will most likely just get you into a good position with an open pelvis and NOT touch the baby until it is born.  A less comfortable MW or a mama that wants it can call an ambulance before the baby is emerging (as soon as the breech is visible).

1- Do homebirth midwives deal well with head entrapment?

2- If a woman doesn't know her baby is breech and her midwife doesn't want to handle it, can she transport?

3- How often does head entrapment occur?

 

Quote:

5.  Uterine rupture.  solution: emergency transport to hospital, emergency c-section and possible hysterectomy for mother.

1- Uterine rupture is more common in vbac's correct?  How often does it happen in a woman with no previous cesarean?

2- What are the signs of uterine rupture?

3- At what point should a transport to the hospital take place?

4- How quickly does a transport need to take place for safe outcomes?

 

Quote:

6.  Baby not breathing after birth.  (I have heard a story of this happening for no apparent reason and the baby died).  My MW was fully trained in neonatal resus and had all the requisite equipment with her.  My DD1 did need suction and oxygen to get going well and it was done very smoothly - baby was taken to window to observe skin tone in good light as they suctioned and gave some oxygen with mask, once she was beginning to stir she was put onto my chest to help her regulate her systems and i held the oxygen tube (with the mask off) under her face so it was blowing against her nose and mouth.  Her apgars were 9, 7 and 10, i think the premature cutting of her cord was what caused the dip.

1- From what I understand, it is pretty common for midwives to be trained to resuscitate babies if they are not breathing, correct?

2- How often are midwives not able to help a baby to start breathing again?  When is a transport to the hospital required?

3- I am assuming a quick transport would be needed.  Is this something generally done at home before the transport?

4- What are the reasons for a baby not breathing?  Can this be detected before hand?

 

Quote:

7.  Placenta accreta/increta/percreta. They would call EMS and transfer for PPH/non-delivered placenta and it would be dx and dealt with in the hospital.

1- I am not familiar with placenta accreta/increta/percreta.  Could someone explain what this is and why it's so serious?

2- How urgent is it?  When does this occur in the labor?

3- How quickly is a transport needed for a safe outcome?

4- What are the outcomes associated with this?

5- Are there any signs of this happening?

 

Quote:

8.  Postpartum hemorrhage.  solutions: pitocin shot, shepherd's purse to manage at home; if bad enough, emergency transport to hospital and pitocin IV and possible blood transfusion.

1- How often does this happen?  I feel like it happens pretty often.

2- Are homebirth midwives generally trained in handling this?

3- How quickly does a woman need to be transported to the hospital for a safe outcome?

4- Are there signs that a mother could possibly begin to hemorrhage? 

 

Again- let's try to be as objective as possible so we can get some real answers and so women can objectively weigh the risks of homebirth against the risks of hospital birth.

 

I appreciate everyone's knowledge and help in navigating this!


Me: New mama to DD born 11/17/2009. We And:
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#11 of 30 Old 12-21-2010, 10:04 PM
 
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I'm glad for this thread and my husband and I are currently weighing the option to HBAC.  Will be following this.


Alicia, wife to an loving and faithful DH, and mama to three fantastic though nutty children (cs, then an HBAC, then a VBAC!!).
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#12 of 30 Old 12-21-2010, 10:13 PM
 
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So from recent studies the average risk of abruption is less than 1%, with term abruption being around .3% or less and with preterm abruption being a much higher risk of about 5%.  


Here is a quote from a study published in Sept 2010,

"During the study period there were 185,476 deliveries, of which 0.7% (1365) occurred in patients with placental abruption. The incidence of placental abruption increased between the years 1998 to 2006 from 0.6 to 0.8%. Placental abruption was more common at earlier gestational age. The following conditions were significantly associated with placental abruption, using a multivariable analysis with backward elimination: hypertensive disorders, prior cesarean section, maternal age, and gestational age." 
There is s pretty high mortality rate associated with abruption since the studies are done for in hospital births being there is not necessarily preventative .. Another study published in08

"Preterm placental abruption is an unpredictable severe complication associated with significant perinatal morbidity and mortality. Factors found to be independently associated with placental abruption were grandmultiparity, severe pregnancy-induced hypertension, malpresentation, earlier gestational age and a history of second-trimester vaginal bleeding."
 
And another older article" Abruption of the placenta at term was found to be significantly associated with PIH, non-vertex presentation, IUGR, hydramnios and advanced maternal age."

There is a smaller subset of women with hyperthyroidism that have increased risk of having an abruption. The numbers are not good even in hospital, but it is a relatively rare emergent event.

Prolapse cord is also a fairly rare risk, that is not necessarily improved by being in the hospital when it happens , the CPM study one of the home birth deaths was an appropriate transfer for unusual heart tones, as a routine procedure the nurse AROM and the cord prolapsed , so this prolapse occurred in the hospital and they did not save the baby. Again the majority of cord prolapsed occur in preterm births, presentation other than vertex, unengaged head at time of rupture of membranes , no cord wraps, IUGR babies ...

As for having a medical back up, may or may not help, depends on your area and who is on call and where your provider is when you transfer in. Larger hospitals have staff on 24 hrs and so will have a team ready, calling ahead and giving report to the head ob nurse or actually getting the on call doc on the line and talking to him/her can expidite transfer . Smaller hospitals can be similar and possibly more crucial to call ahead and get the docs on the way. Emergency transfer can happen quickly .

Things like placenta Previa are usually detected before term , signaled by an early bleed, so many women have ultrasounds now this is rarely a surprise again increased risk for previous csection.
After 2 unmedicated hospital births, in recovery from those births the first book I read was obstetric emergencies .... So I understand wanting to know This stuff, I recommend doing some research via pub med and emed sites as well as doing searches here .
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#13 of 30 Old 12-22-2010, 06:52 AM
 
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Path2Felicity - All the questions you are asking are great and there are good answers to all of them, but you have a LOT of technical and statistical questions.  I think you would be better served by buying a book like Heart and Hands by Elizabeth Davis, which is an introductory textbook for midwives but very readable for parents.  It goes over a lot of this information in a much more detailed and accurate way than what you will be likely to get here.  I am an info-junkie and reading this book when planning my homebirth gave me a basis of information from which to ask questions and also gave me peace that there is a "plan" in the event of an unexpected complication.

 

The other thing that's going to affect the answers is the specific midwife.  Skill sets vary among midwives, so you really need to know what the "right" answers are (for you) and then interview midwives and hear what they say.  Not all midwives are created equal.  For example, some midwives (in my state) carry pitocin and other rx drugs for PPH, and some don't.  You need to know what's available and what you are comfortable with when selecting a mw.


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Quote:
Originally Posted by MeepyCat View Post

.... The more I've looked at how long it takes to transfer, the more I am convinced that situations like placental abruption just can not end well if they occur at home.   

 While this may be true enough if the abruption starts well in advance of delivery, it is actually not true if the abruption occurs within the last minutes prior to delivery.  Most hospital crews would be unlikely to make the best response to a severely hypoxic baby in the early minutes/hours, and their actions could actually do more harm than good before they realized that they needed to be taking advice from whatever Level III NICU is in their region, having the best, most up to date info on saving the life and brain of such a baby.  I know this from experience with abruption occurring in the final minutes of birth-- a baby born at home whose life and brain were saved by being born at home, and thus NOT being subjected to the usual med protocols for neonatal hypoxia in the first 30 min--protocols that work well enough in many hypoxia situations but actually cause more damage in the most severe situations.  The problem is, it can take some time for labs and other assessment methods to show just what a baby needs.  The baby I know will now have the same chance as any other baby to grow up healthy and sound--BECAUSE she was born at home with a very late catastrophic abruption.

 

To be clear, a mw should know signs of abruption during labor, and transfer care as early as possible if abruption is suspected.   Despite my above comments, I do believe that if it is possible to get med help BEFORE an abruption is fully catastrophic, that is the best thing to do in spite of the risk of your baby receiving wrong care at med hands.  The possibility that you will be able to get med help before the worst is done, when the 'usual protocols' actually will be helpful, is worth the risk IMO.  My above comments only apply to last minute abruption during delivery--pretty rare but it is something that can occur without warning.

 

There is much that obstetrical and neonatal med care has to offer to those clearly at risk; unfortunately this is still very much emerging science and still riddled with myths and mystery.  None of us...not the best qualified docs nor the most-well-read mom or mw here...has solid justification for saying anything with too much certitude about this topic.

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#15 of 30 Old 12-22-2010, 07:00 AM - Thread Starter
 
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Quote:
Originally Posted by womenswisdom View Post

Path2Felicity - All the questions you are asking are great and there are good answers to all of them, but you have a LOT of technical and statistical questions.  I think you would be better served by buying a book like Heart and Hands by Elizabeth Davis, which is an introductory textbook for midwives but very readable for parents.  It goes over a lot of this information in a much more detailed and accurate way than what you will be likely to get here.  I am an info-junkie and reading this book when planning my homebirth gave me a basis of information from which to ask questions and also gave me peace that there is a "plan" in the event of an unexpected complication.

 

The other thing that's going to affect the answers is the specific midwife.  Skill sets vary among midwives, so you really need to know what the "right" answers are (for you) and then interview midwives and hear what they say.  Not all midwives are created equal.  For example, some midwives (in my state) carry pitocin and other rx drugs for PPH, and some don't.  You need to know what's available and what you are comfortable with when selecting a mw.


Thanks for the reference, womenswisdom.  I will definitely buy this book.  However, I still would like to create a list like this as a resource so it's also easily accessible to people.  It can be a summary and doesn't have to be an exact science.  But, having a list of what could go wrong and being prepared with a general sense of what we can do about it (or, rather, what a trained midwife can do about it)... well, I think it's helpful to have.  I will do some more research on this today and post what I can find!


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#16 of 30 Old 12-22-2010, 11:34 AM
 
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In the book Baby Catcher, there are two descriptions of placental abruptions. One ends badly (it was a high-risk, planned hospital birth, but the abruption happened at home), and one ends well. But it gives a good description of how a mw should handle this emergency. I actually found it helpful to understand how this is handled from the mw's point of view. Also, it really does illustrate the importance of a good transitionary relationship between home and hospital. The mw was a CNM with transitionary care established in both cases. She had a good working relationship with the hospital, backup docs, etc. The first transfer was hellish and everything that could go wrong, did, with a lot of egos getting in the way of taking care of the mother and baby. The second transfer was smooth, and everyone worked well together... which is no guarantee of a good outcome, but certainly makes a huge difference.

 

I have a lot to say about continuity of care and the lack thereof in the US ans how that should impact decision-making for homebirths...but perhaps that should be for a different thread.


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#17 of 30 Old 12-22-2010, 12:27 PM
 
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My mw just posted a link to this video on FB... it's a discussion on how to deal with shoulder dystocia. There are several more videos there as well. Thought they might be helpful.

 

http://www.youtube.com/watch?v=xJIGAnkw26I

 


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#18 of 30 Old 12-22-2010, 12:43 PM
 
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Originally Posted by honeybee View Post
I have a lot to say about continuity of care and the lack thereof in the US ans how that should impact decision-making for homebirths...but perhaps that should be for a different thread.


I can't speak for the OP but I would love to hear what you have to say on this subject.  I think it is totally relevant to the questions being explored in this thread.


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#19 of 30 Old 12-22-2010, 12:58 PM - Thread Starter
 
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Quote:
Originally Posted by honeybee View Post
I have a lot to say about continuity of care and the lack thereof in the US ans how that should impact decision-making for homebirths...but perhaps that should be for a different thread.


I can't speak for the OP but I would love to hear what you have to say on this subject.  I think it is totally relevant to the questions being explored in this thread.


Agreed!  As people post more and more info, I will go back and update our list.


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#20 of 30 Old 12-22-2010, 03:29 PM
 
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  However, I still would like to create a list like this as a resource so it's also easily accessible to people.

Just curious - what "people" did you have in mind here? My first thought was that you're trying to create the list to "sell" your friends & family on HB. Is that the case?

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#21 of 30 Old 12-22-2010, 04:50 PM
 
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Well, to be honest, I would probably plan a hospital birth with a CNM. But you have to do what feels right for you. I know some women do shadow care with an OB, but I'm not sure how valuable that would actually be in a true emergency. I have to admit I do have a bias toward CNMs because they are they have the best safety record (i.e. better than docs in hospital, and better than CPMs out of hospital.)

 

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I just wanted to add that the research shows that a key element in the safety of homebirth is that the midwife is well integrated into the health system. So I would add in several of the emergencies listed above, that the midwife would call ahead to the hospital to have the OR prepped and the surgeon present. This cuts the delay significantly and is a key condition for me choosing homebirth. In my case, this means I chose a homebirth CNM who collaborates with docs/hospitals to make this link smooth. The awesome homebirth study results in Canada and the Netherlands have a lot to do with how well midwives are integrated into the system overall. And it may also be part of the reason that US homebirth stats look pretty terrible by comparison, since many midwives lack this connection and have trouble facilitating a smooth transfer.



What do you do in my position?  There are no doctor/midwife relationships where I live.  A doctor won't even see me during pregnancy because I'm planning a homebirth.  There is no support whatsoever.  All the CNMs deliver in hospital only.  I know because I called every one for insurance purposes.  I look for a midwife I trust implicitly and assume that upon calling the hospital in an emergency, they listen and believe what we tell them.




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#22 of 30 Old 12-22-2010, 04:52 PM
 
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This is so interesting - MsBlack, could you say more about how the protocols for neonatal recussitation differ at home and in the hospital?

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.... The more I've looked at how long it takes to transfer, the more I am convinced that situations like placental abruption just can not end well if they occur at home.   

 While this may be true enough if the abruption starts well in advance of delivery, it is actually not true if the abruption occurs within the last minutes prior to delivery.  Most hospital crews would be unlikely to make the best response to a severely hypoxic baby in the early minutes/hours, and their actions could actually do more harm than good before they realized that they needed to be taking advice from whatever Level III NICU is in their region, having the best, most up to date info on saving the life and brain of such a baby.  I know this from experience with abruption occurring in the final minutes of birth-- a baby born at home whose life and brain were saved by being born at home, and thus NOT being subjected to the usual med protocols for neonatal hypoxia in the first 30 min--protocols that work well enough in many hypoxia situations but actually cause more damage in the most severe situations.  The problem is, it can take some time for labs and other assessment methods to show just what a baby needs.  The baby I know will now have the same chance as any other baby to grow up healthy and sound--BECAUSE she was born at home with a very late catastrophic abruption.

 

To be clear, a mw should know signs of abruption during labor, and transfer care as early as possible if abruption is suspected.   Despite my above comments, I do believe that if it is possible to get med help BEFORE an abruption is fully catastrophic, that is the best thing to do in spite of the risk of your baby receiving wrong care at med hands.  The possibility that you will be able to get med help before the worst is done, when the 'usual protocols' actually will be helpful, is worth the risk IMO.  My above comments only apply to last minute abruption during delivery--pretty rare but it is something that can occur without warning.

 

There is much that obstetrical and neonatal med care has to offer to those clearly at risk; unfortunately this is still very much emerging science and still riddled with myths and mystery.  None of us...not the best qualified docs nor the most-well-read mom or mw here...has solid justification for saying anything with too much certitude about this topic.




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#23 of 30 Old 12-22-2010, 06:31 PM - Thread Starter
 
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Originally Posted by Gladiola View Post

Quote:
Originally Posted by Path2Felicity View Post
  However, I still would like to create a list like this as a resource so it's also easily accessible to people.

Just curious - what "people" did you have in mind here? My first thought was that you're trying to create the list to "sell" your friends & family on HB. Is that the case?


People who are considering a homebirth and want to weigh the risks with the benefits.  I don't really care who I sell homebirth to, except myself and my husband (and he will basically trust whatever I decide).  I could come up with the most convincing proof for my family, and they would still think I'm nuts... so, frankly, I'm not really interested in trying to convince them.  If I do decide to have a homebirth in the future, I will probably tell as few people as possible about HB until after the fact.


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#24 of 30 Old 12-23-2010, 07:52 AM
 
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First, I need to say that the new MDC site is driving me mad!  Why is it so hard to put one's post AFTER the post quoted...didn't used to be.  Ok, mini-rant done...

 

Mama Metis--

 

It's not so much that the protocols for resus differ, it's that hb mws simply can't do some of the things done in the hospital.  The 02 delivery systems are different, the drugs, blood products, so much is not available at home that is readily available at the hospital.  These things can make a positive difference for your 'average hypoxia' (although I argue that they are OFTEN overused and not as helpful as believed by the medically faithful, and much more often harmful than most ever know), but these things only worsen things for severe hypoxia.

 

And in the early minutes/hours of a severe hypoxic event, it turns out to be very important that the baby NOT become 'hyperoxygenated'--and this is a relative term.  Relative to the hypoxia, that is--one might think that bringing baby's 02 saturation rapidly back to 'the usual normal level' would be the best thing, but it's the worst thing for the severely hypoxic baby, only causing more damage to brain and other organs--02 levels need to be brought back up more slowly while other methods are used to further 'slow down' the baby (below).  Another thing is warming the baby--which is standard protocol in hospitals but again, is the worst thing for such babies.  At home, there are not going to be enough staff people, hands, equipment to warm the baby so 'efficiently' when resuscitation is taking place...and the likelihood of the baby losing some heat while awaiting EMS is pretty great.  Turns out that the current treatment for severe hypoxia is COOLING the baby to around 90 deg F.  And using phenobarbitol or other similar drugs to induce coma--all designed to slow down baby's metabolism greatly, to reduce the secondary damage done by reoxygenation and reperfusion (getting blood back into organs that may have shut down due to hypoxia). 

 

A baby might survive the hypoxia, only to be killed in the following days when their brain is flooded with the breakdown byproducts of cell death occurring during the event.  Free radicals and other biochemicals are set loose by the decaying cells--those biochemicals can cause further harm or death....the phenobarbitol, it turns out somewhat coincidentally, has a chemical composition (if I read this right in the reseearch I did) that can bind free radicals, for instance.  Thus helping prevent free radical damage to the baby's brain/other organs.

 

Now, a mildly-moderately hypoxic baby is going to benefit from warming--although I argue that both mws and docs are way too quick to administer  02 when tons of research shows that room air is the best way to start any resuscitation.  ANY resuscitation.  Mild-to-moderate hypoxia is best corrected initially w/room air--bag and mask delivery or even mouth to mouth--and delivery of 02 should be cautious.  But most mws I know, and every hospital resusc I've seen proves, that 02 is seen as the Holy Grail, the Utmost Panacea.  We've known for decades that excessive 02 can damage babies just as surely as hypoxia--but in the 'panic moments' it is still considered the First Line of Defense...a dangerous myth for any baby, but especially so for the severely hypoxic.  Still, a hb mw is far less likely to be able to deliver the excessive dose of 02 the way the hospital can.  Thus, this apparent 'deficit' of hb care can actually save a baby's life and brain from the highly toxic impact of hyperoxygenation.  If your baby is only mildly-to-moderately hypoxic, then 02 is simply not needed, nor as beneficial to the baby as room air,  at least in the early minutes (while awaiting EMS, for instance).  Look up the RESAIR study, which looked at many thousands of babies and resuscitations involving both 02 and room air.  (sorry, I lost my link in a computer crash last year, haven't replaced it yet)--this study concludes that ALL babies do better when room air is the first thing given by bag and mask.  Some babies do benefit later from 02 supplementation, but all babies started on room air did better on all counts, both immediately and over the longterm. 

 

And it also turns out that an accidental side effect of hb is that EMS is NOT trained nearly enough in birth and neonate care (in most places in the US).  Their 'lack of training and equip' only protects the severely hypoxic baby from the damage of hyperoxygenation and warming too much too soon, of giving stimulant drugs when the opposite is actually needed, for some examples.   

 

Strange, isn't it?  The very things we see as potential deficits for the extremely at risk baby at home, are actually benefits compared to the hospital.  And again, this is because at the hospital they will instantly uload their whole arsenal of 'care' on any threatened baby, while being forced by the limitations of their science to wait for lab info that may prove they only did more  harm than good to such a baby in those early minutes/hours.

 

There is no Holy Grail or Ultimate Panacea.  There is only Life.  We can save more lives, but we can't improve quality of life for anyone through medical science--not any more surely than simply living healthy, in the great majority of cases.  We work so hard for 'control', only to create more backlash for ourselves--all manner of new problems for the survivors of med care and their loved ones.  I'm not saying that modern obstetric and neonatal care has nothing to offer--I've seen some of the good possible (along with the bad).  And I AM saying, again, that we will never change life as it is, with any amount of science.  All we can do is make choices, and stick to them until we really believe a new choice is needed; and find the strength to survive, and the will to heal and find joy again when sorrow strikes...because life can be so hard, but also offers healing and joy. 

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Originally Posted by Mama Metis View Post

This is so interesting - MsBlack, could you say more about how the protocols for neonatal recussitation differ at home and in the hospital?

Quote:

Originally Posted by MsBlack View Post

Quote:

Originally Posted by MeepyCat View Post

.... The more I've looked at how long it takes to transfer, the more I am convinced that situations like placental abruption just can not end well if they occur at home.   

 While this may be true enough if the abruption starts well in advance of delivery, it is actually not true if the abruption occurs within the last minutes prior to delivery.  Most hospital crews would be unlikely to make the best response to a severely hypoxic baby in the early minutes/hours, and their actions could actually do more harm than good before they realized that they needed to be taking advice from whatever Level III NICU is in their region, having the best, most up to date info on saving the life and brain of such a baby.  I know this from experience with abruption occurring in the final minutes of birth-- a baby born at home whose life and brain were saved by being born at home, and thus NOT being subjected to the usual med protocols for neonatal hypoxia in the first 30 min--protocols that work well enough in many hypoxia situations but actually cause more damage in the most severe situations.  The problem is, it can take some time for labs and other assessment methods to show just what a baby needs.  The baby I know will now have the same chance as any other baby to grow up healthy and sound--BECAUSE she was born at home with a very late catastrophic abruption. 

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#25 of 30 Old 12-23-2010, 09:03 AM
 
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I already addressed in another thread the flaw of citing CDC data, which makes no consideration of CPMs.  Do you have other studies or evidence comparing CNM outcomes to those of other providers?  Just curious.  SIL wants a MW but not a home birth, so this would be helpful information to her.  Thanks in advance!  

 

 

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 I have to admit I do have a bias toward CNMs because they are they have the best safety record (i.e. better than docs in hospital, and better than CPMs out of hospital.)


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#26 of 30 Old 12-23-2010, 11:17 AM
 
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MsBlack, thanks so much for the explanation. That's fascinating.

 

Turquesa, I just responded to your point about using the CDC data on another thread. To summarize, your point is totally fair and I agree it's a shortcoming of the data to not break out CPMs separately. But I consider the "other midwives" category to be a fairly reasonable proxy for CPMs. To me the major difference is not which (if any) certifying body a direct entry midwife is affiliated with. The main substantive difference in the training of CNMs and other midwives is that CNMs are educated at the graduate level and are required to have a medical background before entering midwifery. Direct entry midwives, whether they are certified as CPMs or not, do not have these requirements.

 

ETA: Re: your SIL... A hospital birth with a CNM appears to be the safest possible option available, again according to the CDC data. I know this data set has it's flaws, but honestly there is so little good birth data. I'll take what I can get. :)


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#27 of 30 Old 12-23-2010, 06:54 PM
 
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Okay, so, I will  ask my questions regarding each of the complications brought up.  I would like to keep this thread as bias-free as possible- I really hope to get some answers and not speculation and commentary.

 

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1. Cord prolapse.  solution: EMS called, get on hands and knees with butt in the air, midwife or someone holds baby's head up manually to keep pressure off the cord, you ride in the ambulance that way and emergency section at the hospital.

1- How effective is it to get on hands and knees with the butt in the air?  Does that actually help stop the cord from coming out? It is what they do immediately if they see a prolapsed cord in hospital too, the point being to keep the weight of the baby off the cord and prevent it from being compressed, they only lay you flat again as they administer the anaesthetic for the cs.  Effectiveness depends on the position of the baby and cord, the dilation and descent and the experience of the person helping - outcomes are improved though even if the mother is alone and gets into this position.

2- How quickly does a transport to the hospital need to take place in order for a safe delivery? That again depends on the actual situation.  A severely prolapsed and compressed cord which is not being protected despite knee-chest with manual help will damage a baby within 6 minutes and kill it shortly afterwards, but the chances of that happening are incredibly tiny - every occurrence is not the worst possible scenario afterall.  A slight prolapse at the end of labour  (ie if membranes rupture during the onset of the 2nd stage and the head descends immediately and pinches the cord) might do no damage whatsoever if the baby is born quickly.

3- What are the signs of cord prolapse?  At what point should a good midwife start to think of transport? A cord in the vagina or in front of the presenting part during a VE is the main sign - a "hidden" prolapse, where the cord is pinched by the presenting part but still inside the cervix would be detected by worrying hearttones (either tachy cardia or bradycardia).  Any sign of a cord and a good midwife would turn mama knee-chest and call EMS immediately UNLESS she was actually catching the baby already (i.e. noted the cord as membranes broke during same contraction head then crowned).  Midwives have guidelines for heart tones too, depending on their situation (i.e. NHS MW's have quite strict rules they have to obey, but my IM is governed by only the regulatory body, so she is free to follow evidence-based practices and not fear-based ones).  There are parameters of "normal" for heart tones and for most MW's very careful attention is paid if they are abnormal and transport is decided upon based on continued monitoring.  For example my DD's heartrate was 188 during the last contraction before i began to push but dropped to 145 after the contraction ended.  MW could see i was on the cusp of the foetal ejection reflex and waited one more contraction, during which i pushed her head from spines to crowned, and 2 contractions, 4mins, later she was out and salmon pink - she had a true knot, which was probably why descent caused an acceleration so high.  

 

Quote:
2.  Placental abruption.  solution: emergency transport to hospital, emergency c-section.

1- What are the signs of a placental abruption? Pain during gaps between contractions, abnormally long contractions (or belly always hard), "tearing" pain not near the cervix, abnormal foetal heart tones, sometimes abnormal bleeding.

2- When would a trained midwife know when to transport? Through experience alone.  If an abruption is suspected EMS would be called immediately.  Likewise if heart tones are abnormal care would be taken to monitor closely, and EMS called if MW became worried about them/another sign became apparent.

3- How quickly does a transport need to take place in order for a safe outcome?  How quickly does it happen in a hospital?  That depends, as ever on the individual situation.  Mild abruption might not even be dxable before birth occurs, is very survivable and could even be dealt with at home (though of course wouldn't be, deliberately).  Severe abruption is very rare but could kill the baby within 6 or 7 minutes and the mother in a few more.  Babies die of abruption in hospital too, there is no silver bullet, in general if an abruption is dx they attempt to have the baby out within 15mins.  Some babies born within that timeframe still die.  There is a mama on here whose baby girl, Aquila, died of an abruption, but when you read her blog it seems to me clear that the MW was negligent.  She delayed transfer when the mama wanted it, she ignored worrisome heart tones, she failed in her duty of care to that family.

 

Quote:

3.  Shoulder dystocia.  solution: Gaskin maneuver, sometimes breaking baby's clavicle to get her/him out.  This one is time-sensitive enough that it has to be handled at home, and midwives are trained to handle it.

1- When I read Ina May Gaskin's book, she made it seem like her method was effective the vast, vast majority of the time.  Is this true?  Yes, for The Farm they have never had a dystocia which they couldn't free with the Gaskin move.  They probably won't attempt it in hospital though, they move straight to McRoberts.

2- How tragic are the effects?  They can range from none (baby unsticks and is born none the worse) through nerve damage (Erb's palsy is most common, causing weakness in affected arm) to death.

3- How often does this occur and how is it handled in the hospital?  It occurs in about 0.5% of births and is handled in various ways from pre-emptive surgery (your bump is big/you gained too much weight/our ultrasound technician says the baby is large, so we'll give you a cs at 39weeks JIC), to McRoberts (mothers (on her back) legs are flexed right up to a "frog" position to open the pelvis, pressure is applied to lower abdomen (suprapubic pressure), sometimes foetal head is pressed/pulled on and usually a large episiotomy is cut, then Woods' screw method may be tried (large episiotomy is cut, dr puts his hands inside to push one shoulder back and the other forwards and attempt to corkscrew the baby out.  The clavicles frequently break during this maneuver.) then possibly zavanelli's maneuver (head is pushed back inside, cs is performed but this is VERY rarely done as it almost always results in severe injury and possibly death to baby and mother).  Most dystocia's which occur are positional, which is why the Gaskin move is so successful BUT in hospital most women have an epidural and cannot easily/quickly get onto their knees and stay there stable to push so they don't tend to use it in hospital.  Very rarely Gaskin fails and then, at home, a MW will do what she can (mcroberts with suprapubic pressure if she has help (someone skilled has to manipulate the baby to avoid tis neck being injured, so she needs 2 others to push the legs flexed and a 3rd, experienced person, to apply suprapubic pressure) episiotomy and modified woods if she does not.

 

Quote:

4.  Head entrapment (breech). i have a friend whose baby died of this.  It is much more common in mishandled breech births (where a careprovider manipulating, pulling on or sometimes even just touching the baby which causes the baby to unflex its head), so a planned breech HB will very very rarely result in this.  For an unplanned breech the reaction will vary from MW to MW - ask ahead of time.  If the MW is happy and comfortable delivering breeches she will most likely just get you into a good position with an open pelvis and NOT touch the baby until it is born.  A less comfortable MW or a mama that wants it can call an ambulance before the baby is emerging (as soon as the breech is visible).

1- Do homebirth midwives deal well with head entrapment?  It depends entirely on the MW.

2- If a woman doesn't know her baby is breech and her midwife doesn't want to handle it, can she transport? It's unlikely she wouldn't know - a good MW could feel a baby was breech and would of course inform mama and talk choices.  And yes, she could transport if she wanted to do so, and a MW who was not comfortable with breech birth would tell her that she was unable to assist and advise her to do so.

3- How often does head entrapment occur?  I cannot find figures, but it should be noted that along with increased risk of baby being injured with the scalpel (9% with cs breeches compared to cephalic cs births) head entrapment is also a risk of breech cs births, because the uterus can contract down when most of the baby is out, closing the incision site around the neck.  In this case they usually immediately administer general anaesthesia to the mother, to relax the uterus and free the head.  So, again, there is no silver bullet for this one!

 

Quote:

5.  Uterine rupture.  solution: emergency transport to hospital, emergency c-section and possible hysterectomy for mother.

1- Uterine rupture is more common in vbac's correct?  How often does it happen in a woman with no previous cesarean?  Some degree of uterine rupture occurs in around 0.5-1% of women with previous cs's AND in 0.5-1% of women having a medical induction with NO previous cs's.  Food for thought - they will say you cannot VBAC due to the same level of risk they fail to even mention when booking you for an induction-purely-for-post-dates.  Uninduced women who are not VBACing will have a rupture about 1 in 16849 according to a study mentioned here, though the actual link to the study doesn't work.

2- What are the signs of uterine rupture?  Continuous pain at the scar site, non-reassuring foetal heart tones.

3- At what point should a transport to the hospital take place?  Immediately if it's suspected.

4- How quickly does a transport need to take place for safe outcomes?  As ever, depends on individual case - severity of rupture, etc.

 

Quote:

6.  Baby not breathing after birth.  (I have heard a story of this happening for no apparent reason and the baby died).  My MW was fully trained in neonatal resus and had all the requisite equipment with her.  My DD1 did need suction and oxygen to get going well and it was done very smoothly - baby was taken to window to observe skin tone in good light as they suctioned and gave some oxygen with mask, once she was beginning to stir she was put onto my chest to help her regulate her systems and i held the oxygen tube (with the mask off) under her face so it was blowing against her nose and mouth.  Her apgars were 9, 7 and 10, i think the premature cutting of her cord was what caused the dip.

1- From what I understand, it is pretty common for midwives to be trained to resuscitate babies if they are not breathing, correct?  I would expect anyone calling themself a MW would have this training.

2- How often are midwives not able to help a baby to start breathing again?  When is a transport to the hospital required?  Some babies need more help, as Ms Black has outlined so well.  If the baby isn't responding within a few moments to attempts to help the EMS should be called.

3- I am assuming a quick transport would be needed.  Is this something generally done at home before the transport?  The MW begins to breathe into the baby if it is really not making any efforts itself, this may progress to intubation but usually isn't (it's a delicate proceedure in the newborn, usually done in the hospital, though some MWs/EMS can do it) most MWs would use a bag and mask, but whether it does or not, someone will continue to breathe into/for the baby until either the baby breathes spontaneously or a machine is fitted to do so.

4- What are the reasons for a baby not breathing?  Can this be detected before hand?  There are many, some babies are hypoxic due to unseen labour difficulties, some babies have been damaged by hypoxia during pregnancy and have no gasp reflex, some babies have unforeseen chromosomal disorders, some babies have malformations.  Some perfect babies don't breathe, just as some perfect babies miscarry, are stillborn or die of SIDS.  In some cases it can be predicted that problems may occur, in others it cannot.

 

Quote:

7.  Placenta accreta/increta/percreta. They would call EMS and transfer for PPH/non-delivered placenta and it would be dx and dealt with in the hospital.

1- I am not familiar with placenta accreta/increta/percreta.  Could someone explain what this is and why it's so serious?  This is where the placenta has adhered to the actual muscle fibres (not the endometrial lining) of the uterus, or grown into it or grown through it.  It is vastly more common in women who previously had a cs and means the placenta cannot detatch and bleeding cannot stop.  Chemotherapy (to kill the fast-growing uterine cells), surgery (to remove the affected are of uterus) and hysterectomy are on the cards for this complication.  It can be fatal.

2- How urgent is it?  When does this occur in the labor?  It occurs during implantation/pregnancy and generally only becomes apparent later on during ultrasounds (or after baby is born if no ultrasounds are done).  Placenta is usually seen to be low-lying (over the scar) and scanned to investigate why, but occasionally an unseen satelite lobe can attached there and be unnoticed.

3- How quickly is a transport needed for a safe outcome?  Same as PPH, except that it's not likely at ALL to resolve at home.

4- What are the outcomes associated with this?  As i said above, hysterectomy and death are a real possibility.

5- Are there any signs of this happening?  Pre-labor it is usually only seen on scans, though percreta (where it has grown right through the uterus and into other organs) may cause other symptoms depending on the affected organs.

 

Quote:

8.  Postpartum hemorrhage.  solutions: pitocin shot, shepherd's purse to manage at home; if bad enough, emergency transport to hospital and pitocin IV and possible blood transfusion.

1- How often does this happen?  I feel like it happens pretty often.  In around 5-8% of deliveries.

2- Are homebirth midwives generally trained in handling this?  Yes, very much so.

3- How quickly does a woman need to be transported to the hospital for a safe outcome?  Many minor PPH's can be dealt with at home.  A PPH is defined as bloodloss of 500mls+.  Up to 1000mls is considered a minor PPH, over 1000mls is a major PPH.  This is not such a great rule of thumb - an anaemic woman may be fainting with a loss of 400mls, and a large healthy mama may not even notice a loss of 800mls.  Clearly if the PPH is 600mls loss a mama may be just fine staying home once bleeding is slowed, and rushing off to hospital would be unnecessary and potentially dangerous (infection risk, leaving baby home, etc. etc.)  For a large PPH the EMS would be called ASAP and timely transport would be ideal.  Some women will not stop bleeding, despite pitocin, uterine massage and so on.  But this is very VERY rare.

4- Are there signs that a mother could possibly begin to hemorrhage? There are certainly risk factors, interestingly placenta previa increases the risk by about 15 times, but planned cs increases it by 9 times, the next highest risk increase.  Most risk factors the MW would have screened for and discussed (like previa, PIH, PE, obesity etc.), there is no way to dx it before it happens though.  I would personally not feel safe using a MW who didn't carry and know how to use contractant drugs (mine had syntometrine, ergometrine and syntocinon).

 

Again- let's try to be as objective as possible so we can get some real answers and so women can objectively weigh the risks of homebirth against the risks of hospital birth.

 

I appreciate everyone's knowledge and help in navigating this!


ETA - when you read this please remember i'm not a midwife.  I'm just a mama who thought and researched long and hard before i decided where to give birth.  The conclusions i drew i drew from the things i have written (which are not referenced because my eldest is 4.5, and i don't have the studies any more, nor will they necessarily be up to date now) but other people could draw different conclusions.  The one i basically came to was that the things which would REALLY be life-and-death and worth being already IN hospital for but couldn't be diagnosed ahead of time are so incredibly rare it would be like me getting a lift to work every day in an ambulance JIC i'm in an RTA.  But others feel differently and that isn't "wrong", we all have to evaluate risk for ourselves and for our babies.  We all travel different paths in our journey through life.  I was already keen on homebirth, had read the Ina May books, had close friends and also siblings who were born at home, and had witnessed a pretty horrific (and still incredibly special and holy at the same time) induction for post-dates in hospital.  I was already planning to birth at home, when i set out to research i did so to check it was as i believed, safe.  I think if a person comes to it to prove it is dangerous then they could come to that conclusion, perhaps not with good studies but DEFINITELY with anecdata.  Babies do die, it's undeniable.  It's important for every woman to understand what the implications are of her plans, and how they fit with her beliefs and hopes for her future.  It is true that a live baby is the bottom line, but it's not right that it is viewed as the only consideration.  None of us want to be raped, we do not marry the first non-rapist we meet.  Likewise no one is planning the birth that will kill their baby, and it does women a disservice to say "oh, the EXPERIENCE, it's not as important as a live baby" - of course it isn't, but that doesn't mean it's not important AT ALL.

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#28 of 30 Old 12-23-2010, 07:44 PM - Thread Starter
 
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Thank you all so much for adding to this thread.  GoBecGo: THANK YOU! 

 

I will read through it all when I have time (which may not be for a couple of days) and update with thoughts and issues... as well as bring up some of the stuff I found.  As for now... keep discussing :) :) :)


Me: New mama to DD born 11/17/2009. We And:
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#29 of 30 Old 12-26-2010, 06:08 AM
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Also keep in mind that "hospital" is not a one-size fits all term.  I was an L & D nurse in a small community hospital when I had my last homebirth.  I got a lot of criticism from my co-workers about it being unsafe.  But guess what?  We didn't have OBs or anesthesia in-house at any time unless they happened to be there with their patient.  I watched it routinely take 1+ hour to perform an "emergency" c-section at night.  Once we waited over 2 hours to do a section for an abruption.  It would have been far faster for me to start at home and drive to the nearest hospital with 24 hour coverage (about 30 min away) than to be laboring in that hospital and wait for the OR crew.  I now live in a different area where there are four hospitals that have OB and only one has 24 hour coverage.  No one seems to consider that as part of the decision making process when choosing a hospital but for some reason it is a hge concern for homebirthers.   Fortunately the hospital with 24 hour coverage is where I work as a CNM and will have an easy transfer there should it be necessary.

 

Most average or smaller sized private hospitals will not have 24 hour coverage.  Most hospitals with residency programs have 24 hour coverage.  I actually recently left a hospital position at the busiest hospital for OB in the US-- they did not have 24 hour coverage.  When an emergency occured they would page any doctor available and the patient was at the mercy of anyone who responded (often no one).  Most often in the middle of the night only CNMs were available.

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#30 of 30 Old 12-26-2010, 09:58 AM
 
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Quote:
Originally Posted by CEG View Post

Also keep in mind that "hospital" is not a one-size fits all term.  I was an L & D nurse in a small community hospital when I had my last homebirth.  I got a lot of criticism from my co-workers about it being unsafe.  But guess what?  We didn't have OBs or anesthesia in-house at any time unless they happened to be there with their patient.  I watched it routinely take 1+ hour to perform an "emergency" c-section at night.  Once we waited over 2 hours to do a section for an abruption.  It would have been far faster for me to start at home and drive to the nearest hospital with 24 hour coverage (about 30 min away) than to be laboring in that hospital and wait for the OR crew.  I now live in a different area where there are four hospitals that have OB and only one has 24 hour coverage.  No one seems to consider that as part of the decision making process when choosing a hospital but for some reason it is a hge concern for homebirthers.   Fortunately the hospital with 24 hour coverage is where I work as a CNM and will have an easy transfer there should it be necessary.

 

Most average or smaller sized private hospitals will not have 24 hour coverage.  Most hospitals with residency programs have 24 hour coverage.  I actually recently left a hospital position at the busiest hospital for OB in the US-- they did not have 24 hour coverage.  When an emergency occured they would page any doctor available and the patient was at the mercy of anyone who responded (often no one).  Most often in the middle of the night only CNMs were available.


Yes, this.  And even most larger hospitals won't have the most advanced life support systems (the closest Level III NICU is at least 3 hours from me, though there is a major city closer than that). But it isn't reasonable for everyone to deliver at a hospital with a Level III NICU just in case - even though it might be lifesaving if their baby happened to need it.

 

I think most people having homebirths recognize that there are risks involved, and that they may end up in a situation where being at a hospital would have prevented a bad outcome. It's a question of relative risk - continuous fetal monitoring in a hospital might detect a problem earlier, but it's more likely to interfere with the normal progress of labor or result in an unnecessary c-section, which carries its own risks to the life and welfare of the mother and baby. No care provider, hospital or home, can guarantee a good outcome.


DS born 6/03, DD1 born 9/06, DD2 born 10/10, DD3 born 4/14.
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