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#1 of 46 Old 12-13-2012, 06:00 PM - Thread Starter
 
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Hi, all! I'm planning my first birth, which is going to be a homebirth, with a local CPM. I really, really like her, but I've become worried about one thing: she doesn't bring oxygen to births. Is this normal? Does this make homebirth less safe? I noticed that even in Ina May's Guide to Childbirth, she says that this is one of the questions that a prospective client should ask. It just never occurred to me, until much later, because I just got such a great vibe from her and didn't think to ask.

 

I haven't brought it up with her and I probably will, but I wanted to hear what you mamas thought. Thank you so much!


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#2 of 46 Old 12-13-2012, 06:36 PM
 
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Why doesn't she carry oxygen?! That's sort of nutty. It's a pretty basic thing. There are no legal midwives where I had my son, so the midwife who attended his birth didn't have access to things like O2. He's a ball of perfection, but I will always feel a certain level of guilt that he didn't have access to the O2 that would have made his transition to life so much better (shoulder dystocia, blue/grey baby, took him a good 30 minutes to pink up... all this with a healthy, educated, multip mother, no risk signs, no indication that there would be *any* problem).

It's not likely to be an issue at all, but if you need/want it, you're going to need it *now*, not in 10-20 minutes when the paramedics arrive or you get yourself to a hospital. 


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#3 of 46 Old 12-13-2012, 07:14 PM
 
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i don't know if it's really that nutty. the new NRP standards recommend starting resuscitation with room air, so at the very least your midwife should have a bag. maternal oxygen for emergencies is not evidence based and doesn't really seem to make a difference. i would just ask her why she doesn't carry oxygen. and for the record i'm not saying a midwife *shouldn't* carry oxygen, just that she may have a legitimate reason.


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#4 of 46 Old 12-13-2012, 08:35 PM - Thread Starter
 
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 Thanks for all of your input. I think it might have something to do with it being unsafe to transport oxygen, though I'm not sure, as some people clearly transport it without anything terrible happening. Sigh. I guess I'll just ask her about it.


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#5 of 46 Old 12-13-2012, 09:35 PM
 
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I think that oxygen is the least of your concerns when having a CPM deliver your baby.  I'd be more concerned about her training than I would be about immediate access to a tank of oxygen.

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#6 of 46 Old 12-13-2012, 09:42 PM
 
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i don't know if it's really that nutty. the new NRP standards recommend starting resuscitation with room air, so at the very least your midwife should have a bag. maternal oxygen for emergencies is not evidence based and doesn't really seem to make a difference. i would just ask her why she doesn't carry oxygen. and for the record i'm not saying a midwife *shouldn't* carry oxygen, just that she may have a legitimate reason.


This is what my research says also...however, I know one of my midwife's backup doesn't carry oxygen and for that reason, I asked that she try another backup first should she not be able to attend.  I figure that most midwives wouldn't carry it if there wasn't some chance they'd need it.  I do believe  that it is not normally needed.

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#7 of 46 Old 12-14-2012, 04:00 AM
 
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Really now? 

 

I guess my opinion is skewed by my exposure to classmates, etc - all midwives here carry oxygen as it is part of the required equipment for registered midwives. Agreed, with a pp, that resuscitation equipment would possibly trump O2, if you had to choose only one. It's a good discussion to have, for sure!


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#8 of 46 Old 12-14-2012, 04:15 AM
 
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Says the person with only one post on these forums...

I personally would feel a lot safer with a midwife who brought oxygen.


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#9 of 46 Old 12-14-2012, 05:13 AM - Thread Starter
 
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Okay, now. Just to be clear, my midwife has an undergraduate degree at a top tier university, along with five years of training--both practical and professional--before becoming a licensed midwife. She's caught over a hundred babies, has excellent statistics, and has apprenticed with every established midwife in town, some of whom are CNMs (I live in a city in which midwifery is quite popular, and we have a thriving birth community). She's not an idiot and I'm not an idiot for choosing her. I asked the question because I wanted to get feedback from women who view birth as a normal life event, so I'm really confused by the snark coming from a couple of you, especially at mothering. Can we get a moderator up in here?!?

 

Thank you, though, to those of you who responded to the question thoughtfully, without sarcasm that assumed I didn't care about my child. I appreciate that!
 


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#10 of 46 Old 12-14-2012, 06:24 AM
 
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This has some great info. http://www.indiebirth.com/4-questions/ I don't doubt that Maryn would be happy to talk with you more about it via email as well, if you're interested. :)

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#11 of 46 Old 12-14-2012, 07:02 AM
 
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My CPM carries O2 and I've 'needed' it in every one of my births so far.. baby didn't need it after birth , but my large headed babies always have trouble during a long pushing phase (and a bit in transition) and every time i've needed O2 to keep their HRs up/recovering appropriately ..  more than anything though, i feel like the o2 helped my care providers to be more comfortable continuing with what we were doing - more than it was actually necessary for a good outcome, if it had been truly necessary we would have gone to the hospital i'm sure or tried more positions or something. (just like i'm sure if the O2 was that big of a deal in my hospital births they would have done an ECS rather than waiting several more hours for me to push a baby out)


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#12 of 46 Old 12-14-2012, 07:36 AM - Thread Starter
 
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Thanks so much to those of you--the vast majority--who provided such great feedback to me! It's very appreciated. Here's a prompt reply from my awesome midwife via e-mail:

 

"I apologize if I had misspoken. I do carry oxygen to all births - a size D tank, similar to all of the midwives including CNMs in the community providing out of hospital care. What I do not carry is a mask to intubate (this can sometimes help inflate the lungs) and no other midwife in town carries this piece of equipment either. I also do not carry medications like epinephrine (similar to the other midwives in the community) and they do have this medication avialable in the hospital. We would call 911 within 3 minutes of attempting a resuscitation without success so that paramedics could intubate the babe and facilitate transport to the hospital.
 
Great question. Keep them coming!"
 
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#13 of 46 Old 12-14-2012, 10:01 AM
 
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We would call 911 within 3 minutes of attempting a resuscitation without success so that paramedics could intubate the babe and facilitate transport to the hospital.

 

Let's think this one through...

 

9:00  Infant is born, has difficulties that necessitate resuscitation

9:03 Resuscitation is not successful, Midwives call paramedics

9:04 Midwives finish paramedic call, paramedics are dispatched

9:09 Paramedics arrive--this is assuming that they are conveniently close to your house, not busy with another call, etc.

9:10  Infant is intubated--this is assuming that the paramedics have skill in intubating newborns--which many do not.  If they aren't experienced, add another few minutes.

 

Can you hold your breath for 10 minutes?  Can your baby?  

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#14 of 46 Old 12-14-2012, 10:20 AM
 
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I'm a midwife in Virginia, and the midwifery law in our state prohibits us from carrying or administering any controlled substances, including oxygen. Perhaps that's the case where your midwife practices too? If it helps, I've attended about 300 births and have performed several resuscitations, all successfully. I've never needed to use oxygen for any of the resuscitations. In the event that I would need oxygen, it would be available when EMS arrives, which would usually be within 5 minutes of when the call was made. In the meantime, I would be able to oxygenate the baby with room air. The AAP guidelines for neonatal resuscitation recommend beginning resuscitations with room air, and progressing to oxygen if needed.

 

Hope that helps,

 

Kim
 

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#15 of 46 Old 12-14-2012, 11:32 AM
 
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KimPekin - do you carry bag, mask and et tubes? 

I'm puzzled at this further information. That's great that your midwife carries oxygen, but how is she going to use it to resuscitate without a bag and mask? I mean, blowing it over his face is sometimes all that is needed (that's all my son would have needed), but if you're really in trouble, your midwife without a bag and mask will have to do plain old artificial respiration. While there's nothing wrong with this, it remains that there is equipment that could help her maintain an airway (the et tubes), and consistent, safe (no risk of transmission of disease, although, I would hope she at least carries a disposable pocket mask!), and that is also the same equipment that EMTs and hospital staff will use if it comes to that. Heck, *I* had an infant bag and mask at our kids' births! You can get them online, and they're effective and not expensive. 

To be noted, I'm not being critical of your birth choices. I don't know if those comments were directed at me. I just think you should be fully awake of the risks and benefits as you move forward with your birth choices, and I think it's awesome that you're asking these questions of your midwife. 


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#16 of 46 Old 12-14-2012, 11:50 AM
 
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I would either switch midwives or ask where you can get oxygen/oxygen supplies. I don't think I'd do a homebirth without it.


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#17 of 46 Old 12-14-2012, 12:12 PM
 
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Once again, NRP guidelines say DO NOT use oxygen for initial resuscitation. You use room air only. Oxygen can be *harmful*, as many studies have now shown. The time to use oxygen would be if you had a pulse oximeter and you could consult the NRP table of pre-ductal O2 levels to determine whether oxygen were needed. Midwives DO use a bag/mask to resuscitate to be sure they are inflating the lungs at the appropriate pressure. http://hsc.unm.edu/SOM/pediatrics/neonatology/PDFs/NRP%202011%20changes.pdf Ironically, a good year after these changes were instituted, I (an apprentice mw at the time) asked during a transport whether the hospital was routinely using oxygen for resuscitation. The answer was a baffled "yes", as if I were asking something very odd. They were not even aware of the changes.

The time when oxygen might be necessary would be for a mother who needed it after birth due to a complication such as hemorrhage, while waiting for a transport.

Also, quoting numbers from the Wax Study, which has been thoroughly discredited, will not get you very far in this forum, I'm betting.

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#18 of 46 Old 12-14-2012, 01:01 PM - Thread Starter
 
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quantum leap, my earlier comments were not at all directed at you. I asked my initial question because my assumption was that there would be people in this forum (particularly midwives and people who were experienced with homebirth) who could provide me with thoughtful responses, and yours was among them. I think you raise a good point about how oxygen would be transmitted to the baby without a mask to intubate, and this is something that I intend to bring up.

 

I also appreciate the comments of womenswisdom, kim perkin, and wild doula who point out that resuscitating an infant with oxygen may not be ideal anyway. This is something I'll look into more. The reason that I felt better after my midwife's response, however, was because it became extra clear to me that her evidence based practices are consistent with both CNMs and CPMs in our community, which as I've already indicated, have really great outcomes for mothers and babies.

 

Having said that, I find comments from rnra to be rather baffling. First, it was unnecessary, not to mention unkind, to provide me with a step by step schedule of my baby potentially dying. If you take issue with my midwife's response, you could have articulated your critique in a way that assumed I understand how time works, because I assure you I do. I have a PhD after all. See quantum leap for an example of how to do this. Also, if you believe that CPMs lack credentials--which you seemed to suggest in your first response--and most homebirths are attended by CPMs, why are you even ON a thread about homebirth, as it would seem you don't necessarily believe that it's safe?

 

Again, thank you to those of you who took the time to respond and to raise your concerns in a sensitive way! joy.gif
 


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#19 of 46 Old 12-14-2012, 01:20 PM - Thread Starter
 
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Oh, one more thing: I found this link that talks about the benefits of using room air (with bag & mask) and mouth to mouth for resuscitation. There's also a discussion of various studies comparing the use of oxygen and room air. It helped to put my mind at ease, and maybe others will find it useful!
 

 

http://www.homebirth.net.au/2008/04/resuscitation-of-newborn.html


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#20 of 46 Old 12-14-2012, 01:55 PM - Thread Starter
 
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Okay, so here's an update: My midwife got back to me about my question concerning the difference between an oxygen mask and a mask to incubate, and it would seem that they're quite different. A mask and bag are placed over the surface of a baby's face to deliver oxygen, but a mask to incubate requires an invasive procedure that involves placing a tube down a baby's throat. While I'm not 100% positive, It seems that the vast majority of homebirth midwives aren't trained to do this procedure.

 

Based on what I've read about the dangers of oxygen, though, I'm a little hesitant to have my midwife use it in the event that my baby has difficulty breathing, especially when studies show that babies tend to fare better with room air delivered via bag and mask. There are lots of things to consider!


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#21 of 46 Old 12-14-2012, 03:45 PM
 
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Let's think this one through...

9:00  Infant is born, has difficulties that necessitate resuscitation
9:03 Resuscitation is not successful, Midwives call paramedics
9:04 Midwives finish paramedic call, paramedics are dispatched
9:09 Paramedics arrive--this is assuming that they are conveniently close to your house, not busy with another call, etc.
9:10  Infant is intubated--this is assuming that the paramedics have skill in intubating newborns--which many do not.  If they aren't experienced, add another few minutes.

Can you hold your breath for 10 minutes?  Can your baby?  

Actually, yes, let's think this one through...
9:00 Infant is born, has difficulties that necessitate resuscitation
9:03 Resuscitation is not successful, Midwives call paramedics WHILE STILL ADMINISTERING PPV - POSITIVE PRESSURE VENTILATION/ARTIFICIAL RESPIRATION
9:04 Midwives finish paramedic call, paramedics are dispatched. MIDWIVES ARE CONTINUING TO GIVE THE BABY PPV THROUGH THE BAG/MASK AND CHEST COMPRESSIONS IF APPROPRIATE
9:09 Paramedics arrive--this is assuming that they are conveniently close to your house, not busy with another call, etc. MIDWIVES HAVE BEEN GIVING PPV AND CHEST COMPRESSIONS AS NECESSARY THIS ENTIRE TIME
9:10 Infant is intubated--this is assuming that the paramedics have skill in intubating newborns--which many do not. If they aren't experienced, add another few minutes.

I don't know where you are getting the idea that the baby is "holding its breath" for 10 minutes while they are waiting for the squad to come. You continue to perform resuscitation until the squad arrives and then THEY continue resuscitation during the ride to the hospital. The baby is getting oxygen from the bag/mask and chest compressions (rarely needed). Resuscitation being "not successful" doesn't mean you stop giving breaths, it means that the baby has not taken over respiratory effort on its own.

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#22 of 46 Old 12-14-2012, 05:14 PM
 
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If air is not getting into the baby's lungs because they're full of meconium, all the PPV in the world isn't going to keep the baby oxygenated while they wait. It's rare, but certainly there are situations where a resuscitation fails because of the absence of someone with the capability of intubation.


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#23 of 46 Old 12-14-2012, 06:59 PM
 
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I agree with you that there are situations where intubation can be lifesaving, but they are exceedingly rare when dealing with a term, low-risk pregnancy with no signs of distress during the labor.

The following is my understanding of meconium and intubation, which would be outside of my scope of practice, so feel free to correct any misunderstandings I may have. A baby who has already inhaled meconium is not going to be effectively treated with intubation, unless you are meaning intubation for suctioning of the trachea in order to prevent inhalation. If the lung surfaces are coated with mec, it doesn't matter whether air is delivered by PPV or intubation. As long as the trachea is clear and you have an open airway, oxygenation will not be improved simply by intubating.

This AHA article outlines the stages at which intubation may be beneficial, and it does not appear that that is one of them: http://circ.ahajournals.org/content/122/18_suppl_3/S909.full. In fact, it also states "Although depressed infants born to mothers with meconium-stained amniotic fluid (MSAF) are at increased risk to develop MAS, tracheal suctioning has not been associated with reduction in the incidence of MAS or mortality in these infants. The only evidence that direct tracheal suctioning of meconium may be of value was based on comparison of suctioned babies with historic controls, and there was apparent selection bias in the group of intubated babies included in those studies."

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#24 of 46 Old 12-15-2012, 04:45 AM
 
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Moderator stepping in for a moment, here...

 

There are some comments and interjections on this thread that border on removal, however, my experience with our homebirth mamas is that they are compassionate towards folks to have concerns about the choice to homebirth. We see this here on this thread. As a homebirth mama myself, I appreciate being thoughtfully challenged and I welcome folks who wish to learn more about homebirth. That said, if you are generally antagonistic towards homebirth and/or are not here to learn and discuss according to our user agreement, I suggest you either read-only or post in the general birth section. Homebirth mamas wishing to discuss a topic in a support-only environment are very much welcome to begin your thread as "support-only" and I will help honor that request by moderating with that in mind. 

 

Womenswisdom and many others - thank you for your thoughtful explanations!  

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#25 of 46 Old 12-15-2012, 09:34 AM
 
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Homebirth midwives should NOT be intubating, sorry. It is a very invasive procedure and require great skill to get it right, especially in a newborn. Even if you were trained in the theory of intubating, you would never see enough cases in a homebirth practice to become remotely skilled at it. 


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#26 of 46 Old 12-15-2012, 09:56 AM
 
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I was also taught in NRP training last year that room air is now the preferred method for neonatal resuscitation in the UK, and as the US is typically behind in making these kinds of changes, it will be here in the near future as well. 

 

http://www.resus.org.uk/pages/nls.pdf

 

Good for you for being so proactive in your care!
 


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#27 of 46 Old 12-15-2012, 12:34 PM
 
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KimPekin - do you carry bag, mask and et tubes? 
I'm puzzled at this further information. That's great that your midwife carries oxygen, but how is she going to use it to resuscitate without a bag and mask? I mean, blowing it over his face is sometimes all that is needed (that's all my son would have needed), but if you're really in trouble, your midwife without a bag and mask will have to do plain old artificial respiration. While there's nothing wrong with this, it remains that there is equipment that could help her maintain an airway (the et tubes), and consistent, safe (no risk of transmission of disease, although, I would hope she at least carries a disposable pocket mask!), and that is also the same equipment that EMTs and hospital staff will use if it comes to that. Heck, *I* had an infant bag and mask at our kids' births! You can get them online, and they're effective and not expensive. 
To be noted, I'm not being critical of your birth choices. I don't know if those comments were directed at me. I just think you should be fully awake of the risks and benefits as you move forward with your birth choices, and I think it's awesome that you're asking these questions of your midwife. 

I do carry a bag/mask and use that for resuscitation. I also carry a DeLee suction device for meconium, if needed. I do not intubate, but I do carry a laryngeal mask airway (never needed to use it).

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#28 of 46 Old 12-22-2012, 03:59 PM
 
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In Canada all midwives carry oxygen to a home birth. Quite frankly, I wouldn't agree to homebirth if they didn't! They bring oxygen for mom and oxygen for baby. You never know when a real emergency will crop up, and oxygen truly can make all the difference!

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#29 of 46 Old 12-25-2012, 08:17 PM
 
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Originally Posted by WildDoula View Post

Homebirth midwives should NOT be intubating, sorry. It is a very invasive procedure and require great skill to get it right, especially in a newborn. Even if you were trained in the theory of intubating, you would never see enough cases in a homebirth practice to become remotely skilled at it. 

 

I agree. And as a parent, I think that if you feel like you need a provider who does intubation, maybe you should be in a hospital setting. It's important to think about what sets of risks you're comfortable with when you choose to birth at home. Myself, I am more comfortable being at home than in the hospital, where routine hospital procedures cause complications. 


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#30 of 46 Old 01-02-2013, 07:42 PM
 
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Snarkiness is getting me steamed.  I live 5 min from a lovely community hospital with outcomes similar to any other typical american hospital.  If I had a baby in the middle of the night there who unexpectedly required intubation at birth, it could be the nurses or OB doing it, who have practice on plastic dolls at NRP but probably rarely actually intubated.  The on-call pedi can be up to 20 min away.  This is not some third-rate hospital in the middle of nowhere, it's just a typical community hospital.  And you know what?  That's life.  Nothing is instant.  Not at home, not at a hospital.  People always think there is some magic that happens in hospitals that just can't be replicated elsewhere.  Maybe they're right, it's called 'nosocomial infections' and 'iatrogenic injuries.'  Birth where you want, I respect everyone's choices, but let's not create a fairy tale about what happens in hospitals.  

 

An interesting point on the oxygen intubation etc debate is that sometimes having too many interventions at your fingertips delays getting the help you really need.  like O2 for mom in labor- my understanding is that has lost favor, the thought being it doesn't help much and it is one more thing that delays more effective methods of improving the heart rate (like position changes or stopping pitocin).  I think it's good to know that your CPM knows when to call it and get more help, not to just keep trying different things.

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