Midwives-Am I too high risk for a homebirth? - Mothering Forums

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#1 of 17 Old 03-14-2012, 06:17 PM - Thread Starter
 
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I am not currently pregnant at this time, but for my next pregnancy I am looking into possibly a home birth. I have had chronic hypertension that is genetic (Im not overweight and nothing else causes it) that is monitored with medicine, my question is would I be considered too high risk to have a home birth?

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#2 of 17 Old 03-17-2012, 11:12 AM
 
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Chronic hypertension would risk you out of our practice.


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#3 of 17 Old 03-17-2012, 11:36 AM
 
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Not a midwife, but in Colorado it would risk you out per state law. I would guess other states have similar laws but you'd have to look at your regulating department.

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#4 of 17 Old 03-17-2012, 11:42 AM
 
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I wouldn't feel comfortable providing care and planning a homebirth for someone with chronic hypertension either.


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#5 of 17 Old 03-19-2012, 10:02 AM
 
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In my state (Michigan) the consensus among OOH midwives seems to be that a single chronic health problem that is well controlled with one medication is acceptable. So, if you have chronic HTN, are exercising and eating well, and only one medication is needed to control your BP, you could probably get a home birth.

Most of the OOH midwives would probably require a visit with a MFM or comanagement with an OB as some of the antihypertensive meds can also be related to growth restriction issues for the baby.


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#6 of 17 Old 03-23-2012, 02:39 PM
 
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Not a midwife. I have had two hypertensive pregnancies. (I am a chronic who is also medicated outside of pregnancy.)

 

Chronic hypertension carries a 25% risk of superimposed preeclampsia, increased risk of stillbirth, increased risk of stroke, increased rates of preterm labor and placental abruption, increased problems for mom, increased risk of IUGR: this risk is independent of meds and there isn't even consensus on whether they cause them. The medications they can use to treat HTN in pregnancy are limited (no ACEis, no ARBs, they're very reluctant to use diuretics, and CCBs are in limited use).

 

This is not a low risk pregnancy. Many hypertensive pregnancies go well. My first was complicated by severe preeclampsia, my second went smoothly. But you want a provider who is trained in complications.

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#7 of 17 Old 07-14-2012, 03:10 PM
 
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In my state (Michigan) the consensus among OOH midwives seems to be that a single chronic health problem that is well controlled with one medication is acceptable. So, if you have chronic HTN, are exercising and eating well, and only one medication is needed to control your BP, you could probably get a home birth.

Most of the OOH midwives would probably require a visit with a MFM or comanagement with an OB as some of the antihypertensive meds can also be related to growth restriction issues for the baby.

This is not the universal consensus amongst all lay midwives in MIchigan. Fortunately there are some who will risk chronic hypertensives out, which is as it should be.  This is one of the many reasons that lay/CPM/DEM midwives have a bad rap for risky and inappropriate behavior. Michigan needs oversight and licensing to help women choose responsible providers and to ensure that those who take irresponsible risks with mother's and babies lives are held accountable.  It doesn't matter if you have been a CPM/DEM for 5 years or 25 years, taking on high risk clients to birth at home is risky and irresponsible. It's reckless and should NOT be done. Just because it may have worked out ok in the past, or you may have been fortunate and not lost a baby or had irreparable harm done, does NOT mean that it won't happen next time. It's UNFAIR to mothers and their families to take on clients you are NOT equipped to manage. Refer appropriately! Be respected in your field from those in the medical world, for having enough humility and sense to transfer care to a higher credential when needed!

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#8 of 17 Old 07-21-2012, 09:10 AM
 
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I completely disagree with the PP. Since when is it a midwife's job to decided where a mother births? Regulating midwives in BC has led to higher and higher c-section rates as the midwives become little OB's and follow OB protocols. Risk is a term developed by the insurance companies. I strongly believe that no matter where a mother births, her body and baby are HER responsibility. If she chooses to have care with an OB because her pregnancy is "high risk" and chooses an interventive birth, that is her responsibility. Same with if she chooses a homebirth or an unassisted birth. There ought to be care providers of every mentality to meet women where they are. In my province people can have regulated midwives for free, as provided by the government, or they can pa $5000 for an unregistered midwife who can provide them with the birth of THEIR choice. And guess what? There is a lot of demand for unregistered midwives. Just because YOU want to have all midwives regulated does not mean that that serves all women. It is up to each woman to determine her own level of "risk" based on her feelings and intuition about her own body, baby, and well-being. Care providers would best serve women if they could discuss with compassion the risks and benefits to a home/hospital birth with the woman's condition, without fear mongering about who is going to get sued for "allowing" the mother to birth a home. Her body, her birth. To the OP, I would encourage you to read Sacred Birthing by Suni Karl and use the excercises to get in touch with what is going on for you. I guarentee that once you are clear on what your intentions are for this baby and this birth, the perfect birth environment will become clear to you, and you will have the birth that is best for you.
 

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#9 of 17 Old 07-21-2012, 05:47 PM
 
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fairydoula,

if your post was directed at me, I am puzzled. If a midwife asks a MFM or OB for a consult, she is specifically asking them to see the client in question, determine how well her med or meds are controlling her  chronic hypertension and give recommendations as to whether the woman is low risk enough for a birth out of hospital.

 

As a doula do you have training and education that is at a higher level than CPMs or CNMs and MFMs? If not, then I don't think that your opinion of a woman's risk status should define her choices. My answer is based on my experience as a CNM who has worked OOH and with high risk women in hospital. In my practice, if a woman has a condition that is not completely low risk then I send her to the MFM I consult with to be sure she has the best possible advice as to the safety of her preferred birth setting.

 

OTOH if a woman attempts to give birth somewhere she does not feel safe, don't you think that the fear and anxiety involved might increase her risk of complications related to CHTN? Michel Odent seems to feel this is true. He feels that the endorphins and lack of adrenalin are more needed for women who are high risk than for  low risk birthing women. OOH may not be the best choice for women who are high risk, but Odent recommends that as much as possible hospitals caring for high risk women try to recreate a home like environment to decrease the stress involved in the labor and birth environment. And for the OP, one of the adverse events associated with laboring in water is a decrease in systolic, diastolic, and arterial BPs. Laboring in water, where ever you choose to birth would be an excellent therapeutic idea.


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#10 of 17 Old 07-21-2012, 05:49 PM
 
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fairydoula, I just saw your tag which says you are waiting to go to nursing school. I think I just answered my own question about your education and training.


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#11 of 17 Old 07-21-2012, 07:40 PM
 
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AlexisT,

Although you are correct about the numbers and the increased risk, the individual is not their risk factors. That is why consulting with an MFM and watching the pregnancy carefully is so important. Yes, these complications can occur, but there is a 75% chance that she will not develop pre-e. In listing the increased risks, do you have a breakdown of the confounding factors that increase risk: things like obesity vs. morbid obesity, exercise, diet, length of time the woman has had CHTN, whether also diabetic. There are a lot of things that go into these numbers and all those things should be factored in when discussing her  risks.
 


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#12 of 17 Old 07-21-2012, 08:14 PM
 
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I completely disagree with the PP. Since when is it a midwife's job to decided where a mother births? Regulating midwives in BC has led to higher and higher c-section rates as the midwives become little OB's and follow OB protocols. Risk is a term developed by the insurance companies. I strongly believe that no matter where a mother births, her body and baby are HER responsibility. If she chooses to have care with an OB because her pregnancy is "high risk" and chooses an interventive birth, that is her responsibility. Same with if she chooses a homebirth or an unassisted birth. There ought to be care providers of every mentality to meet women where they are. In my province people can have regulated midwives for free, as provided by the government, or they can pa $5000 for an unregistered midwife who can provide them with the birth of THEIR choice. And guess what? There is a lot of demand for unregistered midwives. Just because YOU want to have all midwives regulated does not mean that that serves all women. It is up to each woman to determine her own level of "risk" based on her feelings and intuition about her own body, baby, and well-being. Care providers would best serve women if they could discuss with compassion the risks and benefits to a home/hospital birth with the woman's condition, without fear mongering about who is going to get sued for "allowing" the mother to birth a home. Her body, her birth. To the OP, I would encourage you to read Sacred Birthing by Suni Karl and use the excercises to get in touch with what is going on for you. I guarentee that once you are clear on what your intentions are for this baby and this birth, the perfect birth environment will become clear to you, and you will have the birth that is best for you.

The problem with this way of thinking is that no woman in her right mind is going to make the choice go knowingly endanger her life and the life of her child if she has all of the information about the true risk. Hypertension in pregnancy is no joke. Any health care provider who minimizes the risks to the point that the pregnant woman thinks a homebirth is safe in those circumstances has no business as a health care provider. The most important thing a health care provider can do is offer accurate unbiased information. With the OP's diagnosis, no responsible health care provider would support a homebirth.

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#13 of 17 Old 07-22-2012, 05:08 AM
 
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The difference in the risk is the term "chronic HTN" and "well-controlled chronic HTN".  The perinatal risk is much lower in the well-controlled HTN.  That is easy for a midwife to monitor.  The patient takes her own BP's between visits and the midwife monitors them accordingly.  If a midwife says to her patient, "Call me if you have 2 readings in a row of 140/90 or more," most of our home-birth patients have enough responsibility to do so and be a partner in their care.  Many women seeking OB care don't really want the team approach, and OB's certainly don't offer the team approach.  Actually, midwifery patients would  be watched more closely than OB patients, since patients are getting the BP's done on a daily basis (at home), while OB patients are getting their BP's followed only every few weeks.  All this being said, there is a difference between one midwife and the next (I am recently finding out--as I am a CNM doing home births).  I feel qualified to care for such a woman--in my state I can prescribe and regulate her meds--with 10 years experience as an L&D nurse and 15 as a home birth midwife.  I don't know if I feel a midwife with one or two years of online schooling also following a DEM could be relied upon to properly follow such a patient.  But, I also believe in patient self-determination--she can determine her own needs--but only if she is really informed about the training, experience and qualifications of the midwife in whom she is putting her trust.

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#14 of 17 Old 07-22-2012, 10:57 AM
 
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"Many women seeking OB care don't really want the team approach, and OB's certainly don't offer the team approach."

 

I beg to differ! The CNMs and OBs in practice together, and there are many, do offer the team approach. A woman with chronic hypertension who develops preeclampsia while under the care of a CNM/OB practice is going to have a much better chance of continuing to receive midwifery care than is the woman being cared for by a homebirth midwife (most commonly a DEM) who must refer out of her practice. I don't know what your backup situation is, jocycnm, but most homebirth practices I have ever heard of have next to zero chance of being attended by a midwife if any complications develop. 


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#15 of 17 Old 07-23-2012, 11:19 AM
 
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My OB (a university based practice) does offer a team approach.

 

However, as a chronic hypertensive, I was scheduled for OB only. As a first timer on the NHS, I was also consultant led with all appointments OB. The CNMs at my OBs were allowed to read my NST and check my BP, but I was not allowed to see them regularly. 


Controlled hypertension is not safe hypertension. It does not reduce the risk of superimposed preeclampsia and may mask its development because BPs may stay within normal range. With my first, I began pregnancy with a baseline of 140/95 and finished at 160/105 with 24 hour protein in the thousands. Starting my second pregnancy controlled at 115/75, I would only have been prehypertensive if my rise had been similar. As an OB patient, I most certainly was NOT checked "every few weeks." I monitored my BP regularly at home and I had twice weekly office visits for BP, urine, and NST beginning at 32 weeks as well as regular 24 hour urine tests and growth ultrasounds. The time I spiked a 162/110 I got 24 hours in L&D. That may sound paranoid to you, but it was appropriate. 1 in 4 is not low odds. 


As for the idea about stress, I think that's another way to blame women for a disease that is beyond their control. By the way, I can't get my diastolic to move an inch no matter how angry I get. 

 

Midwives can and do have the right to know their own limitations and refuse care to patients they are not equipped to treat. Speakyourtruth, you are also blaming women: after they are told that their conditions are normal, then they are told they should have known better when things go wrong. 

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#16 of 17 Old 07-23-2012, 05:08 PM
 
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Katie and Alexis you misunderstood my meaning about the team approach.  I meant that the woman is part of the team by making decisions on her own and the Health Care Provider (midwife, nurse, OB) has input, but the woman has the final say.  That is the approach virtually no OB is part of (except a rare few that have blogs here on the internet that I love.)  I had said in my post above, "...most home birth patients have enough responsibility...to be a partner in their care."  I suppose I wasn't clear in my meaning.  Either that, or any OB/Midwife "team" (that I know of) is really an OB/Medwife team.  You won't find an OB/Med/Midwife team where one gives medical care and the other midwifery care.  It's not like if you're seeing the OB, he'll say, "No, you must be induced at 41 weeks..." and the Midwife in the same practice says, "No, we can give you until 42 wks, because that's what the most recent research shows."  No, the midwife does what her OB "team" says--it's not the other way around.  An independent midwife, like myself, can personally tailor the care each woman receives to their individual personality/needs and wants...not what some OB who knows nothing about midwifery care dictates.  No, I don't agree with you that there are such things as OB/Midwife "teams" and certainly none that considers the patient a part of the decision-making process of the team.

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#17 of 17 Old 07-23-2012, 06:27 PM
 
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If a "medwife" is a practitioner that recognizes the difference between normal and pathology, I embrace the label. You sound incredibly arrogant.


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