Apgar Score of Zero at Five Minutes - Page 3 - Mothering Forums

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Old 07-08-2013, 03:43 PM
 
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Homebirthing, one would hope that all midwives would have your standards and call for help as soon as you would, but aside from the fact that the professional standards required for a midwife to stay in practice vary wildly, I think your estimates for 911 response time are optimistic.

I live in a major metropolitan area, close to a lot of excellent hospitals. I know of three locations, less then a mile from my house, where ambulances and ambulance crews are on call to go out in emergencies. The night my daughter was born, I called 911 because I was hemorrhaging (placenta previa) It was twenty minutes before an ambulance arrived at my door. All three of those crews I knew about were already out on calls.

The rural women you talk about, who have a lot of kids and are likely to give birth on the way to a distant hospital, are a classic case for "convenience" inductions, which allow them to arrange childcare in advance and arrive at the hospital before they go into labor. While there are risks to induction, there's also a need to balance those against the risks of birthing unattended, or in a situation where help may take significant amounts of time to arrive. That risk is even greater if there's only one ambulance in a community (not unusual in rural areas). Usual response time is meaningless if the crew already has a patient in the truck.

Also keep in mind that statistical response times published for 911 services don't all have the meaning you seem to expect. Around here "911 response time" means the length of time it takes to get off hold and actually speak to an operator.
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Old 07-08-2013, 04:21 PM
 
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Respectfully, there is a difference between "my state supports" and "the evidence supports" for VBAC, twins, breech in an out of hospital setting.  I support all of those in hospital, as does ACOG, and I understand the frustration when what is sound practice is not available in a hospital setting.  VBAC is probably the most negotiable regarding out of hospital birth (other countries may support it, although no nationalized health provided midwifery care in the world that I'm aware of supports breech or twin out of hospital) but it has evidence suggesting that OOH VBAC carries significant risk.

 

http://journals.lww.com/greenjournal/abstract/2004/11000/results_of_the_national_study_of_vaginal_birth.9.aspx


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Old 07-08-2013, 09:25 PM
 
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I don't have the study, but the first question I always ask is "who paid for it?"

If ACOG wrote it, I wouldn't believe it for a second.

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Old 07-08-2013, 09:33 PM
 
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Originally Posted by loveneverfails View Post

Respectfully, there is a difference between "my state supports" and "the evidence supports" for VBAC, twins, breech in an out of hospital setting.  I support all of those in hospital, as does ACOG, and I understand the frustration when what is sound practice is not available in a hospital setting.  VBAC is probably the most negotiable regarding out of hospital birth (other countries may support it, although no nationalized health provided midwifery care in the world that I'm aware of supports breech or twin out of hospital) but it has evidence suggesting that OOH VBAC carries significant risk.

http://journals.lww.com/greenjournal/abstract/2004/11000/results_of_the_national_study_of_vaginal_birth.9.aspx

surely, forbidding vbac in hospital has left many women feeling no choice but to homebirth if they don't want their babies surgically delivered. I knew a woman who was asking around on one of the ap groups for someone to allow her to attempt vbac in a home near a hospital. She lived too far from one for her comfort. Everything went fine though.
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Old 07-08-2013, 09:49 PM
 
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 However, if the midwife is unlicensed and not a CPM at minimum, then what incentive does she have for remaining current in resuscitation?

 

Um, being responsible? Educated?

 

I stay current in resuscitation and I'm not licensed yet. I have a flow chart poster that I made on my fridge. We do practice drills. Being unlicensed doesn't mean that you don't do things.


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Old 07-08-2013, 10:17 PM
 
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You're right again. :) My percentages are off by a decimal point, but the ratios remain the same. So, like you said, the chance is still 10X greater (hospital MDs vs. home birth midwives). 

 

I also thought it was interesting that the hospital midwives had half the 0 Apgar scores as MDs. I'm guessing that is partly due to the fact that the midwives are going to be dealing almost exclusively with the low-risk groups, while MDs cover all births - including all high-risk ones.

 

I have to say I am disturbed that home birth midwives have 18X the chance of having an Apgar score of 0 at five minutes than hospital midwives have. As you say, there are circumstances that are going to require equipment that isn't available at home. Transfer is obviously what you want to do when the baby is born with an Apgar of 0, but when 5 minutes have already gone by and the Apgar is still 0 and the paramedics haven't arrived yet...I don't like the thought. And the question also is, were there warning signs during labor (that should have led to a transfer) that the midwife missed? 18X higher is just crazy. 

 

This reminds me of something years ago... I don't remember exactly (or maybe it was described to me?): a box of cereal reads "100% asbestos-free!", leading the consumer to believe there is surely asbestos in all the other cereals.

 

Or like how the chance of prostate cancer goes up X% if you Y, but really it's still extremely, extremely low.  18x higher, when it's still ~1 out of 6 THOUSAND babies is perfectly acceptable, imo.  Incredibly unlikely.

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Old 07-08-2013, 11:00 PM
 
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Aggie, your math is wrong.  It's 1 in 600 home birth moms with a midwife, and that counts none of the moms who transferred.  That number could be higher.  1 in 6,000 is hospital, MD.  But I agree that 1 in 6000 feels very low.  I would not agree that 1 in 600 is low at all, and this does not capture very well the rate of babies who were damaged but not so severely compromised in utero that they managed to get a 5 minute Apgar of 0.  Damage is still very possible with a 5 minute Apgar of 5.


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Old 07-09-2013, 06:44 AM
 
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It's 1 in 600 home birth moms with a midwife,
Can you show how/where you get this? I agree that the number will be higher if all pre 3rd stage transfers are counted as hospital. But, then with these small numbers, maybe we would want to factor those unplanned OOH births, unattended, planned HB demise, and though I support CPMs that would be helpful to know too.

I wish the study went more into why they chose the 5 minute apgar score? If most babies with a zero 5 minute apgar at home pass away, I feel a little like this is another way to look at morbidity stats. Am I the only one thinking this? Is this really Infoemation about more morbidity/mortality or another way of looking at stats we already know?

Thus is why I wish this study (which reads really short? - is what we have a condenced version?) went into more detail about relevance and etc.

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Old 07-09-2013, 07:26 AM
 
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. The night my daughter was born, I called 911 because I was hemorrhaging (placenta previa) It was twenty minutes before an ambulance arrived at my door. All three of those crews I knew about were already out on calls.
.

Was your birth a planned HB?

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Old 07-09-2013, 07:42 AM
 
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Sure, no problem.  Table 2 shows the rate per 1000.  The rate for hospital MD is .16 per in every 1000 women, rate for home midwife is 1.63 per 1000, rate for hospital midwife is .09 per 1000.   1000/1.63= 613.  I am not sure why I had it as 600 instead of 613, and I apologize for the discrepancy.  .09/1000 for hospital midwife is 1 in 11,111.  Those numbers make me wince quite a bit.  The P value for these relative risks is very very very low at p < .0001, so likelihood that this is a fluke is extremely low.

 

I think that they chose the 5 minute Apgar of 0 because it represents a high degree of fetal compromise, and outcomes are markedly worse for a 5 minute apgar of 0.  If you've been resuscitating for 5 minutes and you still have an Apgar of 0, completely flat baby, you are looking at a pretty hefty risk of brain damage.  A 1 minute of 0 is terrifying but if resus is strong, that can still be baby with no neurological consequences at all.  With a 5 minute Apgar of 0, you know that that kid has been not breathing and with no heart beat for at least 5 minutes.  Risk of hypoxic brain injury would be pretty high from that I would think, although we don't know what the risk of neurological injury is when you're looking at the 3, 5, 5 Apgars either and that seems far more likely to happen than a 5 minute of 0.  But 5 minute Apgar of 0 doesn't mean automatic death, although the outcomes when you don't have access to intubation and ventilation, a full crash cart etc would probably be significantly poorer than if one did have access to those things.  It may not mean death, but it certainly means brain function.  This stat, as far as I can tell, is about what babies with what caregiver in what setting have what risk of finding themselves in serious damage where brain damage to death is likely.  I find it really helpful because mortality is only part of the picture.  We have no real numbers on what the risk of hypoxic brain injury is for home birth, and that I think is probably the elephant in the corner.  

 

Identity, did you mean you feel this is another way to look at morbidity or mortality stats?  And for the record, I'm not convinced that the home, CNM stats are actually going to be better than the CPM.  The educational advantage should play in favor of CNM having better numbers, however if the CNM in question is practicing because she got fired from a hospital and sets up a home birth practice, her stats may reflect that instead of people choosing knowingly to practice home birth.  

 

Could you explain more what you mean about why unplanned OOH should be counted?  I'm not quite following you on this point and I'd love it if you could clarify a bit?


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Old 07-09-2013, 07:50 AM
 
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Was your birth a planned HB?

 

Hells no!  Placenta previa.  I started hemorrhaging at 10:23 p.m., had to stumble around the house, bleeding, to wake DH and find my cellphone, DH called 911 around 10:40, ambulance arrived a little after 11 p.m., arrived at hospital ~11:15. DD delivered by c-section at 1:04 a.m., 32w4d gestation. 

 

Help may realistically not be there at 5 minutes post-partum, even if you call them promptly.

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Old 07-09-2013, 08:03 AM
 
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Was your birth a planned HB?

 

Not Meepy, but my last home birth was a planned home birth with an emergency newborn transfer followed by a lengthy NICU stay.  It was 6am and the ambulance was probably there within about 5 minutes of when we called, but the transfer was a complete disaster.  We had a midwife assistant spending precious minutes arguing with paramedics over what hospital to go to and carseats in ambulances, and we wasted easily 20 minutes in front of the house with a baby who had already stopped breathing once.  This was after a 3 hour delay where we had non-zero but still bad Apgars with a baby who never came around right, but we trusted our midwife and she told us we didn't need to transfer yet.  On arrival in the NICU, we had a kid with absolutely horrible labs.  It is a miracle that she is ok, but it took years for us to really see the depth of how much danger she was in... and how much less danger she would have been in with faster access to emergency medical care.  Just because the ambulance is there fast doesn't mean that you are going to be at the hospital fast and getting emergency care as fast as needed when time is brain.

 

And I'm not out with pitchforks against home birth or anything of the sort.  I will never choose home birth again, but I do not want home birth banned. We don't even know whether this is a problem everywhere in the US or whether it's specific states with horrifying stats and some with excellent stats averaging out to the 10x higher risk.  But I am aggressively in favor of informed consent discussing all of the relevant evidence regarding home birth safety, strong educational standards and regulation, and better practice guidelines for emergency transfers.  


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Old 07-09-2013, 08:20 AM
 
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LNG, I'm on holiday and typing from my phone.

What I meant is that when talking about these small numbers things like whether unplanned OOH births are included can be important. Did the study say? I can't recall.

And when I said this is another way of looking at morbidity - that's because if most of these babies passed away, these cases have been looked at.

Stepping lightly here...

We have some HB mamas who feel the forum is not a comfortable place to discuss these difficult issues because of participation by those who do not support HB. We want this forum to be a comfortable place for HB mamas to discuss these topics. Mothering has clarified guidelines for posting. When participating from a perspective outside of the HB community, please be especially forthcoming. Meepycat, it is easy for members to assume incorrectly, for instance, that you had undiagnosed previa from a planned HB from you post here in the HB forum. For clarity's sake, please be upfront a out posting outside the forum guidelines. LNG, I think the issue of transfers is the most important thing for HB in this country (US). I also had a glitchy transfer. I place the responsibility on ther entire system to improve transfers for HB (and stories like MC).

These guidelines are new so I am going to give a period of adjustment for those members who do not support HB accostimed to posting here. Pls. Let me know if there is a need to discuss these issues in a more diverse setting and I will see where we can host that.

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Old 07-09-2013, 08:30 AM
 
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These are not including the "whoops, baby in the high school bathroom" births.  That there is a midwife listed as the attendant *might* include cases where the midwife walks in 30 seconds after a baby is born, but it isn't going to include people who planned a hospital birth or who didn't know they were pregnant at all and had a birth at home.  This is strictly women who had a midwife recorded as the attendant who delivered at home without antepartum or intrapartum transfer.


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Old 07-09-2013, 08:32 AM
 
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Just to clarify, do I still count as "in the home birth community" as someone who has had 3 home births but who will not choose home birth again?  I want to make sure that I am being adequately respectful of the setting here.


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Old 07-09-2013, 08:46 AM
 
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LNF, thanks for clarifying about MW attendant. I dislike when folks can't be bothered to read the study but still feel entitled to comment... Like I appear to be doing. :-) I read it but am foggy from the beach and it takes forever to switch pages on my phone. Sorry for that.

As for your participation here, read the guidelines. If the fit for you (if you are posting to learn about or in support of HB, this is your spot). There is room for folks outside of this but the assumption is the above and members posting outside of the guidelines should clarify that an we will moderate on a case by case basis. Thanks for asking and being respectful of the intentions of the forum and its members! :-)

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Old 07-09-2013, 08:55 AM
 
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Meepycat, it is easy for members to assume incorrectly, for instance, that you had undiagnosed previa from a planned HB from you post here in the HB forum. For clarity's sake, please be upfront a out posting outside the forum guidelines.

 

No, I was not planning a homebirth. 

 

Politely, though, I think that's entirely tangential to my point, which is that you cannot rely on a certain response time from 911.  If I had planned a homebirth, the response time would not have been faster.  I felt that your question implied that planning a homebirth would have made my experience somehow different in that regard.

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Old 07-09-2013, 09:11 AM
 
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LFN I also chose a hospital birth with my last child after 3 planned homebirths + two unplanned hospital births in the middle (a non-emergent transport during labor and a transfer of care just prior to labor). I don't know if I will have another homebirth, would probably depend on a lot of things. I still support homebirthing mothers, not sure I can say the same for some (anecdotal) practices I've heard going on. 

 

As far as the subject at hand. When I was pregnant with #5 I was sick earlier in the pregnancy and passed out on my il's front lawn. We live in a small town about 25 miles from the hospital. First responders got there fast, ambulance crew took longer, but it went reasonably quickly. However, just a few months after my daughter was born my fil had a heart attack and died before they got him to the hospital. They took him by flight but it still seemed to take a long time to get everything moving. It was long enough that I woke up and dressed 5 children and myself and had them in the van before the copter took off. My husband, who was doing cpr, believed he was gone before they even got there, so I am not blaming them for his death at all, but the reality was that it didn't go as fast as it would need to with a baby in serious trouble and they fumbled around looking for equipment that cost them time. Also I understand that first responders generally have little to no training in birth or newborn rescucitation, if they even have the equipment on hand that fits. So, yes we talk about the 30 minute transfer rate in terms of setting up the OR for sectioning a baby in a bad situation, but when the baby is already here?  I don't know, but I think that is something moms need to be aware of when choosing home birth.

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Old 07-09-2013, 09:14 AM
 
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MC, I was not implying that your experience would have been different. I posted to clarify that your birth was not a planned HB, a reasonable assumption in this forum. Though I disagree that your experience may not have been different with a planned HB, it may well have. You may have been recommended bed rest, more frequent monitoring, and your MW may have been there before the paramedics, may have advised a better transfer doctor, acted as a doula and etc. Of course maybe not.

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Old 07-09-2013, 09:25 AM
 
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Estimated transfer time has come up a lot recently. I do agree that there are factors often not considered. Like in my case having transition contractions while trying to get to the car.

There are definitely those unanticipated circumstances where the hospital would have been the better choice. Sure would love to know more about those 64 births. For me a lot of this has me wondering, "which ones of those could have been me?"

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Old 07-09-2013, 09:34 AM
 
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Aggie, your math is wrong.  It's 1 in 600 home birth moms with a midwife, and that counts none of the moms who transferred.  That number could be higher.  1 in 6,000 is hospital, MD.  But I agree that 1 in 6000 feels very low.  I would not agree that 1 in 600 is low at all, and this does not capture very well the rate of babies who were damaged but not so severely compromised in utero that they managed to get a 5 minute Apgar of 0.  Damage is still very possible with a 5 minute Apgar of 5.

 

arg, sorry.  mental math in the middle of the night is bad.

 

still, i think 1 in ~600 is low.  Then there's the problem of "damaged" babies who were revived in the hospital for a life of varying degrees of difficulty.  Don't really want to go into my thoughts on reviving people "heroically."

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Old 07-09-2013, 09:47 AM
 
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Sure, no problem.  Table 2 shows the rate per 1000.  The rate for hospital MD is .16 per in every 1000 women, rate for home midwife is 1.63 per 1000, rate for hospital midwife is .09 per 1000.   1000/1.63= 613.  I am not sure why I had it as 600 instead of 613, and I apologize for the discrepancy.  .09/1000 for hospital midwife is 1 in 11,111.  Those numbers make me wince quite a bit.  The P value for these relative risks is very very very low at p < .0001, so likelihood that this is a fluke is extremely low.

I don't really understand statistics but to get to the "1 in x" number you don't divide the number if 0 apgers by the number of HB?

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Old 07-09-2013, 09:59 AM
 
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MC, I was not implying that your experience would have been different. I posted to clarify that your birth was not a planned HB, a reasonable assumption in this forum. Though I disagree that your experience may not have been different with a planned HB, it may well have. You may have been recommended bed rest, more frequent monitoring, and your MW may have been there before the paramedics, may have advised a better transfer doctor, acted as a doula and etc. Of course maybe not.

 

ICM, I was on bed rest. I was being followed, extensively, by CNMs at a hospital with a great rep for natural birth practices, and high-risk OB at a hospital with a Level III NICU.  The team on the floor at L&D was fantastic, and I don't recommend holding out for different OBs in my situation.  The ONE thing a HB midwife might have been able to differently in the circumstances is act as a doula.  She could not have made the ambulance get there faster.

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Old 07-09-2013, 09:59 AM
 
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arg, sorry.  mental math in the middle of the night is bad.

still, i think 1 in ~600 is low.  Then there's the problem of "damaged" babies who were revived in the hospital for a life of varying degrees of difficulty.  Don't really want to go into my thoughts on reviving people "heroically."

I agree. I think all should be done, if it can be done, but having worked as an EMT and in several other medical fields, I can see the statistics above skewed by heroic efforts that end up with mortality statistics not much better than the out of hospital ones.

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Old 07-09-2013, 10:17 AM
 
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This is the most important part of this study for me:

 

"Physicians also have the professional responsibility to address the root cause of patients’ motivations for out-of-hospital delivery through continuous efforts to address patient concerns about interventions, and to improve compassionate and safe care of pregnant, fetal, and neonatal patients in the hospital setting." 

 

Personally, home vs. hospital wouldn't be nearly as big of a debate if hospitals were better places in which to give birth. Out of my real life friends, those of us who care about natural birth, skin to skin, etc. don't really care where it happens as long as we are with trusted caregivers. It's just that "the hospital" is not often enough one of those safe places. 


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Old 07-09-2013, 10:27 AM
 
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I don't really understand statistics but to get to the "1 in x" number you don't divide the number if 0 apgers by the number of HB?

 

My numbers were based on the rate calculated per 1000 by the study authors.  There were 98 total confirmed Apgars of 0 in the home birth, midwife group out of over 60,000 births, all parities.  The hard numbers are 98 women out of 60,296 midwife attended births completed at home, singleton full term and normal birth weight, had significant enough fetal compromise to result in a 5 minute Apgar of 0.  60,296 divided by 98 gives a rate of 1 in 615.265306.  

 

For first time moms at home, it is worse.  Those hard numbers were 35 full term, singleton normal birth weight out of 14,801 births completed at home for a rate of 1 every 422.885714 having a 5 minute Apgar of 0.  


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Old 07-09-2013, 10:42 AM
 
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Got it!

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Old 07-09-2013, 11:05 AM
 
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arg, sorry.  mental math in the middle of the night is bad.

 

still, i think 1 in ~600 is low.  Then there's the problem of "damaged" babies who were revived in the hospital for a life of varying degrees of difficulty.  Don't really want to go into my thoughts on reviving people "heroically."

 

At the same time, we don't know how many babies were revived in the hospital with more success because they had access to crash carts and intubation who would have been a 5 minute Apgar of 0 without access to aggressive resuscitation but because of access had a 5 minute Apgar of 5, or how many started to have heart tones crash to hell and were lights blaring c/s with apgars of 1 and 8 at 1 and 5 minutes respectively.  I think it's far more likely that a home birth baby winds up being revived heroically because no one wants to give up before absolutely everything has been tried and the kid didn't even have access to the crash cart and ventilator, and then have severe brain injury that might have been prevented if the intubation and epinephrine was available at minute 3 instead of minute 23.


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Old 07-09-2013, 12:35 PM
 
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I'm following this discussion with interest. Currently 28 weeks pregnant with my 4th and planning my 2nd homebirth (first two were born in hospital). I've been sitting on the fence about another HB this entire pregnancy. I agree completely with cynthiamoon about what drives many (including me) to seek OOH birth in the first place. I am very wary of having another hospital birth for fear that my wishes regarding treatment of the newborn will be ignored and met with resistance. My DD2 was vaccinated and given abx against my wishes in hospital, with the reasoning that because they couldn't find my medical records (I had preregistered with the hospital, THEY made a mistake) she needed to be treated as though I'd had no prenatal care and my demands were ignored. I remember all too well the hostile, disrespectful treatment we received.

Because of incompetent care by a MW (not my MW, but her back up) during my last delivery, I'm also wary of going the homebirth route this time. We switched to a different MW team, because although we thought our MW was great, she now practices with the MW we felt failed us. I am concerned because the nearest hospital that accepts HB transfers is about 20 min from us. Like Meepycat I've also had a chance to experience slow ambulance response times. When I miscarried last fall I hemorrhaged and my MW called 911 for me. The first responders were quick, but the ambulance took almost 30 minutes to get to my house. This leaves me with very little hope for a quick transfer should we need one.

I feel like my options aren't great. This study adds food for thought.

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Old 07-09-2013, 01:01 PM
 
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I'm following this discussion with interest. Currently 28 weeks pregnant with my 4th and planning my 2nd homebirth (first two were born in hospital). I've been sitting on the fence about another HB this entire pregnancy. I agree completely with cynthiamoon about what drives many (including me) to seek OOH birth in the first place. I am very wary of having another hospital birth for fear that my wishes regarding treatment of the newborn will be ignored and met with resistance. My DD2 was vaccinated and given abx against my wishes in hospital, with the reasoning that because they couldn't find my medical records (I had preregistered with the hospital, THEY made a mistake) she needed to be treated as though I'd had no prenatal care and my demands were ignored. I remember all too well the hostile, disrespectful treatment we received.

Because of incompetent care by a MW (not my MW, but her back up) during my last delivery, I'm also wary of going the homebirth route this time. We switched to a different MW team, because although we thought our MW was great, she now practices with the MW we felt failed us. I am concerned because the nearest hospital that accepts HB transfers is about 20 min from us. Like Meepycat I've also had a chance to experience slow ambulance response times. When I miscarried last fall I hemorrhaged and my MW called 911 for me. The first responders were quick, but the ambulance took almost 30 minutes to get to my house. This leaves me with very little hope for a quick transfer should we need one.

I feel like my options aren't great. This study adds food for thought.

I am so sorry that you feel like you have such bad options.  I can relate in many ways.  My solution that is working this pregnancy is that I'm delivering in the hospital, but I went with a family practice doctor who will really go to bat for me if I need it, and because he's family practice he takes care of both me and baby.  My contact with other physicians is minimal.  

 

Maybe something like that would be an option for you?  If there are other hospitals in your area, maybe talk to local doulas about what options might be around that would be better for you?  The more you investigate perhaps the more clarity you'll have, because at least you'll know for certain whether you really don't have any hospital option that is workable for you.


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